Lord Falconer of Thoroton: My Lords, I have to inform the House that the Clerk of the Parliaments has received a letter from the Clerk of the Sheriff Court of Lothian and Borders, informing him that the Lord Watson of Invergowrie, having pleaded guilty to wilful fire raising, was sentenced to 16 months imprisonment on 22 September.

Lord Drayson: My Lords, my understanding is that that is not the case and that we are talking only of a minority in the Iraqi police service. As for the training, the Ministry of Defence is responsible for the basic training of the Iraqi police service; and individuals from our own police service have been supporting the detailed training of the Iraqi police—and that is built on that. We are bringing to the attention of the Iraqi Government any incidence that we see of human rights abuses, and we are working strongly to root out those elements in combination with the Iraqi police service itself.

Lord Warner: My Lords, the Government support international development and NHS employers are encouraged to allow staff the opportunity to undertake work to support healthcare systems in the developing world.
	We welcome the call from the Royal College of Physicians to enable overseas trained doctors working in the NHS to undertake time limited periods supporting health systems in developing countries where this is of benefit.
	Through the Tropical Health and Education Trust we are also supporting NHS Links which enables healthcare workers to engage with health projects in the developing world.

Lord Faulkner of Worcester: My Lords, I thank my noble friend for that reply. I am sure that he will agree that the contribution made by the British Transport Police in the aftermath of the attack on the London Underground on 7 July was outstanding. Is he aware that the extra anti-terrorism measures that the BTP have put in place have cost the force a further £5 million, which so far the Government have not given any indication that they are prepared to meet. Does he accept the principle that if we ask the force to take on duties that affect the security of all of us it is not reasonable for the railway industry to meet the whole cost?

Lord Davies of Oldham: My Lords, I am sure the whole House will agree with my noble friend that we did very much appreciate the work of the British Transport Police on that disastrous day of 7 July. Their response showed how prepared and efficient they were, together with the other emergency services.
	I hear what my noble friend has said. He will recognise that there has been an increase of 21 per cent in the budget for this coming year in the light of the difficulties. The industry is responsible for the majority of the funding, but the Government recognise that there is additional funding related specifically to the issues of terrorism and the safety of passengers and staff, which necessitates an increased Government contribution. There has been a contribution over the past year, an increased one over the coming year, and a three-year projected increase of support for that necessary expenditure.

Lord Davies of Oldham: My Lords, the transport police must be efficient in responding to both demands. Regarding illness and disability, the noble Baroness will recognise that we have been concerned to improve the quality of the response of transport to the needs of the disabled or those who become ill in all circumstances. That is why we have recently passed legislation to enhance the requirements and demands upon transport to respond sympathetically to such issues. But she will recognise that the burden of the questions today has been about the very real dangers that are presented to our transport system by terrorism and I want to reassure the House that both the industry and the Government recognise the need for extra, effective expenditure in that area.

Lord Davies of Oldham: My Lords, that is an important point, particularly relating to issues about the capital city, about which my noble friend is well-informed. He is right that changes to the structure of police forces in the United Kingdom necessitate a response to, consultation with and understanding of the role the British Transport Police plays in circumstances where we all recognise that difficulties have accrued in recent years due to the terrorist threat. I assure him that the changes to the police will also involve the fullest consultation with the British Transport Police and that all issues are adequately covered.

Baroness Blood: My Lords, I have listened carefully to what the Minister said but, first, I should like to take issue with the noble Lord, Lord Smith of Clifton. The recent riots in the streets in my area were not about the Whiterock parade; nor, indeed, were they about the Orange Order, in case anyone has that idea. It was the match that ultimately lit the rioting but that was not the reason for it. It has been known for many months that this was going to happen.
	The Minister was asked what is going to happen and what is being taken forward now. My community is most anxious to hear that. I can tell you that I have lived in Northern Ireland all my life and I have never felt the fear that is in my community today.

Lord Rooker: My Lords, at the end of my original Answer in response to my noble friend, I said that the Government are currently developing a multi-stranded strategy to engage with the wider loyalist community. We need to be able to seek discussions with them across a wide range of issues. I do not think that any section of the communities in Northern Ireland should feel that they have been left behind. There is no doubt that some aspects of the Protestant working class feel that but, so far as I have been able to see in the short time that I have been there, the Protestant working class in Northern Ireland has not been represented by working-class Protestants. The fact is that those voices must be listened to.

Lord Mackay of Clashfern: My Lords, I beg to move that House take note of the Report of the Select Committee that was appointed last year to examine a Bill presented by the noble Lord, Lord Joffe, known as the Assisted Dying for the Terminally Ill Bill.
	I was privileged to chair the Select Committee, and I shall open by summarising the way in which the committee went about its work and the conclusions to which it came. All this is set out in the committee's report, which was presented on 4 April this year as House of Lords Paper 86. I hope that, in summarising the work that has been carried out, I will be able to provide an appropriate introduction for our debate today. I will focus only on the main issues.
	The Bill introduced by the noble Lord, Lord Joffe, which lapsed with the dissolution of Parliament in April this year, sought to provide medical assistance with suicide to adults who had been diagnosed as terminally ill with a few months to live, were suffering unbearably and wished to end their life prematurely. Effectively, it would have authorised a doctor to write a prescription for lethal medication that it would then be up to the patient to take—or not, should he or she have a change of heart. In the case of people whose physical condition was such that they could not use such medication, the Bill provided that a doctor might administer a lethal drug to the patient at his or her request.
	The issues with which the Select Committee had to grapple, being issues of life and death, are awesome and sensitive. They arouse strong emotions on the part of those who wish to see a change in the law and of those who feel that such a step would be dangerous. Clearly, opinion on the matter is divided in the country, and it was divided in the committee. It was not surprising, therefore, that we had some lively exchanges as we proceeded. I take this opportunity to place on the public record our appreciation of the time and effort that a large number of people, in this country and abroad, devoted to helping us understand their views on the issues involved. If I say that the committee saw over 140 witnesses in four countries and that it received over 60 submissions of written evidence and some 15,000 letters and other personal submissions from individuals, the House will appreciate the scale of the task and of the help that we received. We are also grateful for the help that we received from Foreign Office officials, the committee staff and specialist advisers.
	We examined the Bill introduced by the noble Lord, Lord Joffe, from the standpoints of ethical principle and real-world practicality. We examined the philosophical or moral principles that underlay its provisions and the practical implications of carrying it out if it were to become law. In terms of principle, we gave close attention to the propositions that assistance with suicide or euthanasia were natural extensions of patient autonomy and that the existing rights of patients to refuse life-supporting treatment implied a corresponding right on the part of those who were terminally ill to receive, if they wished, medical assistance to end their life.
	On the other hand, we examined the arguments that patient autonomy, although an important aspect of medicine, cannot override medical ethics—for example, a patient cannot insist on having surgery that is not considered to be in his best interest—and that there is a crucial difference between a patient deciding to die by refusing further treatment and asking a doctor to end his or her life. We did not find a consensus on the relative weightings to be given to the arguments, with some members arguing that patient autonomy should be paramount, and others that it could not justify weakening the law on intentional killing and assisting suicide.
	On the practical side, we looked at allegations that doctors were already ending the lives of patients prematurely, though we found no reliable evidence of that. We considered whether advances in palliative care obviated the need for change in the law. We concluded that such care can do much more now than it could 30 years ago to reduce or even eliminate the suffering associated with terminal illness and that Britain was a world leader in that branch of medicine, though we were told that its availability was as yet unevenly spread over the country.
	We considered whether there were good grounds for believing that changing the law to allow medical assistance with suicide or voluntary euthanasia was tantamount to stepping onto a slippery slope, with any new law becoming more widely applied than Parliament intended and with medical practice undergoing a subtle but significant shift as a result. As in so many areas of the debate, we heard arguments in both directions. On the one side, it was argued that there was no hard evidence of "slippery slopes" in countries that had legalised such acts or of people other than those for whom the law was designed being drawn into assistance with suicide or euthanasia through subtle external pressures; and, on the other side, it was argued that the Abortion Act 1967, which is perhaps the nearest parallel to a law of this nature, had produced an unintended situation of abortion on demand; that the Bill was seen, as the noble Lord, Lord Joffe, told us, as simply a first stage in relaxing the law; and that in Holland there were already pressures, three years after the passing of the law permitting euthanasia, to extend its provisions to new categories of people.
	We looked also at the difficulties inherent in defining such qualifying conditions as "terminal illness", "unbearable suffering" and "mental competence" and concluded that, while a creditable attempt had been made in the Bill to produce workable definitions, the realities of medical prognosis, the problems of separating out depression from mental incapacity and the wholly subjective nature of "unbearable suffering", called for further work in those areas.
	In the course of the inquiry, we visited the American state of Oregon, where only medical assistance with suicide has been legalised; the Netherlands, where both assisted suicide and euthanasia are legal and where the latter predominates in practice over the former; and Switzerland, where only assistance with suicide is legal, although it is not seen in a medical context and anyone can give assistance with suicide, provided that he or she does not act from selfish motives. In the course of those visits, we discovered that the death rate from assisted suicide is very much lower than the death rate from euthanasia. One in 714 deaths in Oregon in 2003 resulted from patients themselves taking lethal medication prescribed to them under the law. In Holland, one in 38 deaths resulted from assisted suicide or voluntary euthanasia.
	Finally, we commissioned a review of public opinion surveys that have been conducted over the past 10 to 20 years. It found that there appeared to be a groundswell of opinion in favour of a change in the law, although it added that the public opinion research that had been carried out was of a simplistic "either/or" or "yes/no" nature, with little or no attempt to explore the subtleties of the subject and with very little public understanding of the issues involved. Indeed, one of our objectives in presenting our report has been to try to elucidate this complex and emotive subject and to provide a basis for intelligent debate.
	So what conclusions did we come to after all this work? As I said, there was no consensus in the committee on the acceptability of the Bill introduced by the noble Lord, Lord Joffe. Therefore, bearing in mind that because a Dissolution of Parliament was in prospect the Bill would be unable to proceed, we agreed to present a report that summarised the evidence that we had heard in such a way as to avoid drawing conclusions and provided a readable and intelligible guide to the subject. In that way, we hoped to provide a basis for a reasoned debate in the House and for the development of informed opinion in the country as a whole. I hope that the House will agree that, although we did not succeed in coming to clear conclusions on the Bill itself, we succeeded in that respect at least.
	As for the future, we recommended that the House should debate the subject again at an early opportunity in the light of our report, and that is why we are here today. We also felt that, in the event that another Bill was introduced, its author should take account of a number of concerns that had been raised with us in the course of our inquiry. The first and perhaps the most important is the need to draw a clear distinction between assistance with suicide and voluntary euthanasia. We recognised in our report that, while the most careful attention must be paid to the views of the professions that would be in the front line of implementing any change in the law, a decision on whether assistance with suicide or voluntary euthanasia should be legalised was one for society as a whole to take through its legislators in Parliament and that we should give due weight in that process to public opinion. However, we also recognised the corollary: there is a need to look behind the results of opinion polls in order to ascertain the extent to which the views expressed are based on informed opinion and, if we are to avoid the risk of damage to the ethics of a profession that is vital to all our needs and that is—not wholly, but largely—opposed to a change in the law, we must consider how best the implementation of any change might be managed. We also felt that the qualifying conditions that appeared in the Bill introduced by the noble Lord, Lord Joffe, would need to be revisited in any future Bill.
	As a lawyer, I feel that I should say something about the existing law on the subject before I conclude. I must pay tribute to the advice that was given to the committee by the noble and learned Lord, Lord Goldsmith, the Attorney-General, who did so in his capacity as legal adviser to the House. The position may be summed up as follows: the law does not forbid suicide, although those institutions that have in their care persons with suicidal tendencies, such as prisons or hospitals, must take reasonable care to prevent them giving effect to those tendencies. However, the law forbids helping someone to take his or her own life and ending someone's life at his or her request, although the law is not implemented in such a way as to visit the maximum sentence on anyone who acts in that way. Every case that comes to notice is considered on its merits by the police and by the Director of Public Prosecutions to assess whether a crime has been committed, and, if so, whether the circumstances justify a prosecution. If a prosecution is successful, the court must consider whether a custodial sentence or some other sentence is called for. That flexibility in our law was recognised recently and commended by the European Court of Human Rights.
	In the circumstances, as chairman of the committee, I have refrained from expressing a personal opinion, either in the committee or in the House; and I do not propose to express any such opinion now. We have tried to produce a report on which all the committee could agree as a basis for today's debate.
	Moved, That this House takes note of the report of the Select Committee on the Assisted Dying for the Terminally Ill Bill [HL] (Session 2004–05, HL Paper 86).—(Lord Mackay of Clashfern.)

Lord Joffe: My Lords, it was a privilege, and, indeed, an education, to be a member of the Select Committee, chaired by the noble and learned Lord, Lord Mackay of Clashfern, who has so meticulously summarised the report. I should like to express my appreciation to the noble and learned Lord, Lord Mackay, and the other members of the Select Committee, all of whom gave up so much of their valuable time to consider my Bill which lapsed at the end of the last parliamentary Session.
	In my view, three key recommendations were made by the committee. First, that if a Bill similar in nature to the existing Bill were introduced, it should, following a Second Reading, be sent to a Committee of the Whole House for examination. Secondly, that while the most careful account must be taken of expert evidence, at the end of the day the acceptability of assisted suicide or voluntary euthanasia is an issue for society to decide through its legislators in Parliament. The evidence to the committee was of an apparent groundswell of public agreement with the concept of euthanasia and a shift from opposition by many professionals.
	Thirdly, that in England and Wales there is a small but significant number of terminally ill patients who, given the choice, would wish to avail themselves of assistance to die in order to bring an end to their unbearable suffering. These were generally patients with strong personalities and a history of being in control of their lives who, to quote the report,
	"are unlikely to be deflected from their wish to end their lives by more or better palliative care".
	It is only for these patients that assisted suicide was proposed as an option, which they may wish to exercise, and I and other supporters of the Bill have made it crystal-clear in our evidence to the committee that we are totally supportive of palliative care for the overwhelming majority of terminally ill patients and it is misleading for opponents of the Bill to infer otherwise.
	In the evidence given to the committee, concerns were expressed about the possible adverse effect of the proposed legislation on vulnerable people and on the medical profession. Inevitably those concerns could only be speculation about what might happen. From the evidence the committee received in Oregon and the Netherlands, it was clear that the same concerns and predictions of abuse of the legislation had been expressed in these countries prior to legislation. Yet, after many years of practical experience, there was no credible evidence that vulnerable people had been put at risk, or that there was a slippery slope, or that the medical profession had been disrupted, or that the ethos of medicine had changed for the worse. It was also clear that, far from palliative care having been undermined, it had flourished since the legislation was passed.
	The system that most impressed the committee was that in Oregon, where only assisted suicide is permitted and which is working well. The noble Earl, Lord Arran, will in his speech outline in greater detail why the majority of the committee was impressed with the Oregon system. I will accordingly restrict my comments on the Oregon system to a talk at Westminster by Dr or Professor Stevens from Oregon given subsequent to the publication of the Select Committee report. Many of the views expressed by Dr Stevens were repeated in an article by the noble Lord, Lord Alton, in a Catholic publication called The Universe and by the noble Baroness, Lady Finlay, in a number of public talks without even a reference to the fact that those views were in most respects diametrically opposed to those of all the responsible organisations and researchers who gave evidence in Oregon. In weighing the value, if any, to be placed on Dr Stevens's views, I invite your Lordships to study the evidence given to the committee by Dr Stevens and his close colleagues Drs Hamilton and Toffler and particularly their responses to questions 991 onwards.
	I draw attention to the principle of personal autonomy upon which the Bill is based; namely, that competent adults should have the right to make decisions on their own lives, which naturally includes the decision as to when and how they should die. Nobody else—including doctors—should have the right to make such decisions. There is one limitation to this right and that is that in making such decisions, vulnerable members of society should not be placed at risk. The Bill recognised this and incorporated an array of more than 20 interrelated safeguards and was itself far more restrictive and tightly drawn than the legislation in the Netherlands or Belgium and had even more safeguards than that in Oregon.
	I realise that I am fast approaching the end of the recommended time for speeches. However, I have been advised by experienced Members of your Lordships' House that, as it is my Bill which is the subject of the committee's report, it would not be unreasonable for me to talk a few minutes longer. I hope that your Lordships will bear with me as this is not a timed debate.
	Much of the passionate opposition to this Bill is based on religious beliefs. I naturally respect the religious beliefs of those who express or share those beliefs, although I should add that public opinion surveys show that a massive majority of both Protestants and Catholics do not share the views of their religious leaders on this issue. The question that arises is whether a relatively small minority of society has the right to impose its beliefs on members of society who do not share them. In contrast, this Bill does not seek to impose anything on anybody. It simply provides another end-of-life option which terminally ill patients can accept or disregard as they choose.
	I am aware that there is a divergence of opinion among those suffering from disabilities. Public opinion surveys of the disabled show that the majority would support the Bill. I cannot agree with the view of the Disability Rights Commission that although it has no objection in principle to the Bill, it should be delayed until all disabled people have equal rights with the rest of society. I personally totally support the battle of the disabled for equality and I greatly respect and admire the courage of those with disabilities, in this House and elsewhere, battling for equality for the disabled. But I say to them that this Bill is not about disability in general, nor about that crucially important battle for equality by the disabled. It is about terminally ill patients only, all of whom will be fully protected, to the extent that protection may be necessary, by the safeguards in the Bill.
	In the Select Committee, reference was made to evidence given by me to the committee to the effect that the Bill was a first stage and that there was the possibility of subsequent amendment to widen its scope. That evidence was correct. However, when further questioned on that evidence, the report records my answer as,
	"a first stage and possibly the final stage, but there could be subsequent stages"—
	an answer, incidentally, that has been carefully overlooked by opponents of the Bill. Naturally, the question of future stages will be a matter for future legislators.
	I carefully listened to the evidence given at the Select Committee. During its course, I gave notice of a number of amendments to meet concerns that were expressed, including that there will be no obligation on physicians to raise the possibility of assisted dying with patients and no duty on hospices or hospitals to permit assisted dying on their premises. I will include those amendments in a new Bill which I propose to introduce after this debate. When drafting my proposed Bill, I, naturally, will consider all the matters raised in the Select Committee report, the speeches that are made in this debate and any other feedback that I receive.
	In conclusion, the Select Committee report recommended that in any future Bill a clear distinction should be drawn between assisted dying and voluntary euthanasia. Having discussed this recommendation with seven of the 13 members of the committee—a majority—I established that all seven would support the principle of a Bill which limited its application to assisted suicide where the patient takes responsibility for the final stage of ending his or her life. Extrapolating from experience in Oregon, that would be likely to result in about 650 deaths a year. Accordingly, I am minded to recast the new Bill to provide only for assisted dying. I will make a final decision after considering what is said in this debate.

Baroness Finlay of Llandaff: My Lords, I had the honour to serve on the Select Committee. Those pressing to change the law tell us that what they euphemistically call "assisted dying" encourages the development of good palliative care. Let us look at that claim. One of the many letters I received during the course of our inquiry was from two consultants, who described a 31 year-old woman, living in Holland, with an advanced cervical cancer.
	She chose to return home to Newcastle because, she told them, she was being offered euthanasia on every doctor's ward round, like a treatment option, and had felt pressured to accept the offer. In Newcastle, they dealt with her problems of pain and incontinence, and she was able to spend several weeks with her three-year-old son before dying peacefully from her illness.
	The evidence that our committee heard in Holland illustrates their lack of specialist palliative care. We heard that 84 per cent of those requesting euthanasia are in pain, and 70 per cent have difficulty breathing—not good palliative care by any standards. One in 32 dies by such means there, not the small numbers of which the noble Lord, Lord Joffe, has spoken. Volume III of our report has evidence from Dutch physician Bert Keizer, who wrote:
	"I would rather die in a country where euthanasia is forbidden but where doctors do know how to look after a dying patient in a humane manner than I would in a country where palliative medicine is ignored but euthanasia can be easily arranged".
	And increasingly, Dutch doctors feel that economic measures in healthcare will increase the pressures on physicians to provide assistance in dying.
	But what about Oregon? As In Holland, palliative care in Oregon is not an accredited medical specialty. Last year, the Journal of Palliative Medicine reported that, after seven years of legalised assistance with suicide, palliative care in Oregon for people in the final week of life had actually worsened. Three years ago, another report on end-of-life care in the US found that less than 20 per cent of Oregon hospitals had palliative care programmes, and it gave Oregon a Grade E for end-of-life care. However, we are being told that Oregon is the model to follow, and that the take-up rate of assisted suicide is small. Well, every annual report into the working of the law by the Oregon health department has the caveat:
	"Our numbers are based on a reporting system for terminally ill patients who legally receive prescriptions for lethal medications and do not include patients and physicians who may act outside the [law]".
	Its annual report data are based entirely on interviews with prescribing physicians. In 1999—two years after the legislation—it candidly admitted that,
	"the entire account could have been a cock and bull story. We assume, however, that physicians were their usual careful and accurate selves".
	The report ends with an interesting warning:
	"Again we remind all our physician readers that prescriptions written under the Death with Dignity Act must be reported".
	All this was clarified in a letter I have received in the past few days from the Oregon health department, confirming that,
	"there is no central register of prescriptions written by doctors in Oregon".
	It goes on to say that the Oregon health department,
	"would not be able to detect a prescription written for physician-assisted suicide but not reported to us".
	The latest Oregon health department report confirms that the percentage of patients referred to a specialist for psychological evaluation has declined from 31 per cent in 1998 to only 5 per cent now. Yet excluding depression, which occurs in more than one in five such patients, is key to assessing competence. And Oregon's data indicate "doctor shopping". More than two-thirds of patients changed their doctor to get a lethal prescription written, so the doctor writing the prescription knew little about them beyond the case notes.
	Why do people seek death? Overwhelmingly, people who ask to die are confused, depressed, feel that they are a burden, feel unconnected to the world around them, and are fearful. The great majority of ill people go through this as they grieve for their health and the life they used to have. I have had the honour of caring for many thousands of such patients, but the present law protects them from harming themselves.
	Even the most determined can have a change of heart. In 1991, a GP referred a young dying man to me, asking for help because the man only wanted euthanasia; he was refusing all care and his GP did not know what to do. With a prognosis of weeks, he was desperate to die, but pain and immobility gradually improved. Ten years later his wife died of pancreatic cancer, leaving him lone parent of their three children. Now he says to me, "Ilora, don't go there. I cannot bear to think what would have happened to my kids if I had been able to have euthanasia". But he fulfilled every criterion of every assisted dying Bill I have ever seen, and there is no doubt that he would have gone ahead with it.
	Palliative care is advancing rapidly. New drugs are emerging, as are better ways of using the ones we have. Doctors who care day in, day out for dying patients know that, whatever was the case 30 years ago, you no longer need to kill the patient to kill the pain.
	Let us be crystal clear about what "assisted dying" really involves. It is not giving a little more morphine or sedative so the patient can relax and let go of life. No, it is a massive overdose of barbiturates—50 times the therapeutic dose—and, in the case of euthanasia, the Dutch protocol advises an injection of curare to paralyse the patient completely to prevent breathing. Where the overdose is taken by mouth, as in Oregon's assisted suicides, those who ingest it sometimes do not die for more than 30 hours and a few even wake up again.
	This is a Rubicon that we must not cross. When I was a newly qualified doctor, I thought that we should allow euthanasia, but now I am certain that even physician-assisted suicide is too dangerous to adopt and that the words of the Hippocratic Oath are as true today as they ever were. They state:
	"I will neither give a deadly drug to anybody who asked for it, nor will I make a suggestion to this effect"

Baroness Jay of Paddington: My Lords, I have been passed a note which states that the list of speakers has been changed. With the permission of the House, I shall therefore speak now instead of my noble friend.
	It was a great privilege to serve on the committee under the absolutely exemplary chairmanship of the noble and learned Lord, Lord Mackay of Clashfern. His leadership enabled us to produce this unanimous report and to reintroduce the subject of assisted dying into this new Parliament. As has been said, everybody who served on the committee learned a great deal from our extensive inquiries. I found it an enormously educative experience. I remind the House that I was a member of the previous committee, which, 10 years ago, recommended that the legal prohibition of assisted dying should remain. However, I have been convinced both by the ethical arguments of personal autonomy and by the practical issues of patient choice in 21st-century medicine to change my mind. I now believe very strongly that the law must change.
	In the brief time allotted to us all today, we are bound to make points about a complex subject in headline terms. My first headline is that it is extremely important for Parliament to listen to public opinion. After all, this is a difficult legal and ethical issue, but everyone has personal experience of death and of dying. Polling evidence can always be challenged, but no responsible survey that I have seen has shown less than 70 per cent support for a change in the law. Would it be that many of the measures which we pass in this House had that level of approbation.
	I remind the House of what was said by the noble and learned Lord, Lord Mackay of Clashfern. He said:
	"A key finding of the committee was that while the most careful account must be taken of expert evidence—
	I bow to no one in my respect for the position of the noble Baroness, Lady Finlay of Llandaff, and of the other doctors we have listened to—
	"at the end of the day, the acceptability of assisted suicide or voluntary euthanasia is an issue for society to decide through its legislators in Parliament".
	Expert medical evidence quite rightly played a large part in our inquiries and medical opinion appears to be changing. One eminent doctor who gave us evidence told us that he hoped that opposition to the Bill of the noble Lord, Lord Joffe,
	"wouldn't become the last bastion of medical paternalism in this country".
	I shall briefly address some of the concerns of palliative care which the noble Baroness, Lady Finlay, has just raised. I believe that doctors in her specialty remain more adamantly opposed to the change in the law than many of their colleagues. I shall précis their arguments, again in headline terms. They argue—and the noble Baroness argued this most articulately throughout our hearings—that their specialist services can solve all the concerns of a dying person and therefore remove the need for assisted suicide or voluntary euthanasia.
	Like the noble Baroness, Lady Thomas, I see no dichotomy at all between supporting, extending and improving every type of palliative care and supporting the Bill of the noble Lord, Lord Joffe. As a health Minister and through my very long associations with the National Health Service, I have always supported the hospice movement and palliative care in all its forms, but this is not an either/or question.
	One of the most telling lessons we learnt as a Select Committee was that for some terminally ill patients—and we should not argue on the basis of particular anecdotes—palliative care, however expertly given, is just not the solution. For such people, who are probably always in a minority and perhaps a small minority, the loss of independence, control and dignity—which is what one might call a much more existential form of suffering—is what makes them seek assisted suicide. We saw that vividly illustrated during our visit to the state of Oregon; personally, I would hope that our legislation would closely follow the Oregon Death with Dignity Act rather than the experience in the Netherlands. A recent research report, written by our committee's special adviser, Dr Farsides, noted:
	"There was nothing to suggest that the Act had had a detrimental effect on end-of-life care . . . it would appear that change has taken place in parallel to concerted efforts . . . to care for dying patients".
	So in practice it is not an either/or situation.
	Also in her review, Dr Farsides noted that there was no evidence of the so-called slippery slope—the increased demand made by the availability of assisted suicide in Oregon. Since the legislation for physician-assisted suicide, the numbers of people using the provisions of the Act has remained stable and small for eight years.
	I give a final headline. The experience of Oregon shows that far more people ask for a lethal prescription than actually use it. For many, it is seen as a comforting insurance policy against unbearable suffering. Most importantly, it gives the patient ultimate personal control over when and how they die—over the end-of-life decision. In our very civilised secular society, I do not believe that we can deny that final right to our citizens. This Government have a proud record in social policy of extending and improving human rights. The Select Committee has indicated a clear way forward. A new Bill, to be introduced by the noble Lord, Lord Joffe, can provide an historic opportunity to add to that record. I follow my noble friend Lord Carter in asking the Minister to receive this report favourably and for the Government to give the Bill a fair wind.

Lord Patten: My Lords, I think that His Holiness Pope Benedict rather makes the right point when he warns against the dictatorship of relativism. I warn the noble Lord, Lord Joffe, that he may be mistaken if he tries to corral those who do not care for his Bill as being just a few religious persons and the leadership of the Churches. I have one very close friend—I wish that I had asked his permission to quote him today—who I can describe only as a High Church atheist, so passionate is his disbelief in God, who feels exactly the same as many people who do not care for the Bill of the noble Lord, Lord Joffe.
	That brings me to my third point, which is the need not to destroy our trust in the medical profession, for patient autonomy can oh so quickly give way to medical and to state power. I trust my medical advisers, at least at present. I think that they will never harm me and that they will do their best, although, of course, everyone is fallible and mistakes can be made. However, that trust comes about not because of my belief that doctors have some superior moral quality but because of their tradition of doing no harm, held by those of faith and of no faith. In the face of that, and with great respect to the Select Committee, I would have wished that the committee, which quite properly considered the conscientious objections of doctors and nurses, had addressed the conscientious objections of patients and the rights of patients to know about the attitudes of their doctors. That is an oversight. Should the Bill of the noble Lord, Lord Joffe, reach the statute book in some form, we would de facto have to make provision for patients who wished to know what kind of doctor was going to treat them: a doctor who cared to preserve life and a doctor who, in shorthand—or in "headline terms", to borrow the excellent phrase of the noble Baroness, Lady Jay—was really a "vet" doctor prepared to take part in the end of life. There would need to be separate training, and separate registers of the two classes of doctors would have to be made public. The Select Committee might have usefully considered a little more the pragmatic and conscientious feelings of patients themselves as well as those of doctors.
	Fourthly, should a Bill like that of the noble Lord, Lord Joffe, ever see the light of the statute book, it surely cries out for a sunset clause after five years, or whenever. If there was ever such a case, it is this Bill.
	Finally, I admire no one more than the long-running Minister who will reply to the debate at about midnight. I have a couple of questions for him, as I have sensed a certain amount of news management in the air from sources quite close to sources that are close to government saying that, should a Bill like that of the noble Lord, Lord Joffe, come forward, the Government are minded to give it government time. I should like the Minister to say specifically what the Government's intentions are in this matter. I am hopeful that he will answer that question. If his answer is that the Government intend to give the Bill time, I ask him and his colleagues to pause, first, because I think that it would cause amazement among the public that a government led by the right honourable gentleman the Prime Minister—this particular Prime Minister—should go down that route and, secondly—I hasten to add that I myself make no accusations in this regard—that it will raise fears among many that extending government time for this Bill means that the Government wish to save money on the National Health Service in future months and years if it becomes law. I do not know that that is the case and I am not suggesting that it is, but those arguments will run. The Minister can set those arguments to lie now or later in his winding-up speech, if he wishes.

Lord Garden: My Lords, I too am grateful to the Minister for repeating the Statement made in the other place and for sending me an advance copy. The sympathy also of these Benches goes to the families of the British servicemen who have been killed and to the families of the many American servicemen who have died since we last discussed Iraq, in the summer. Nor would we wish to forget the increasingly large number of Iraqis killed and maimed in the continuing violence. We are now seeing 40 fatalities a day.
	We all agree that this is a key week for the Iraqi people as they are asked to vote on the draft constitution. I am pleased that a consistent definition of what "voter" will be in this referendum has been decided, as it looked as though that was going to cause yet more trouble. But on the Minister's assertion that the political process is on track, can he assure us that he has a contingency plan in the event that the constitution is rejected, which must be one possible outcome?
	There remains the question of what the United Kingdom forces can achieve. The Minister listed his three objectives. From these Benches, we have on numerous occasions drawn attention to the need for a proper strategy which couples the security process to economic and political development. Yet the continuing cry in this Statement, as in previous ones, is that the Government's strategy is to stay there for as long as the Iraqis want. Last week, I listened to President Talabani at Chatham House, and he said that he thought he would need us for one or two years. Vice-President Cheney seems to have a longer timescale in mind—he tends to talk in decades. Can the Minister say whether President Talabani confirmed his assessment of one to two years in his talks last week with the Prime Minister?
	If we lack a coherent strategy for the way forward, then our troops really will be in difficulty. Can the Minister tell us the relative priority in the tasking at the moment? How many of our 8,000 troops are tasked primarily with training security forces? How many are on border patrol? How many are on security duties with patrolling as their primary activity? How many are on infrastructure projects?
	Then, there is the issue of the operational tempo, about which we have all worried in the past. Can the Minister give us some idea of how the continuing strain of Iraq is affecting retention in the regular forces and in the reserves. The Chief of the Defence Staff was quoted in a newspaper interview this month as worrying about the effect of Iraq on recruiting. Does the Minister share that worry? Will deployments to Afghanistan be adjusted if the Iraq situation deteriorates?
	Are we doing everything possible to support our troops on these difficult tours? When repeating the Statement the Minister did not mention NATO. In the past we have heard that NATO was helping us in all of this. How is that going?
	The Statement dealt in some detail with the complex rotation plot for our troops, and we understand that there will be resulting small fluctuations in numbers. However, as the noble Lord, Lord Astor of Hever, said, there are reports of a shortage of air transport aircraft to return those who are due to come back to the UK. It is intensely demoralising to be expecting to return and then to be left in a transit area for days because of aircraft unavailability or unserviceability. We cannot, of course, risk our troops in an aircraft where the defensive aids are not working, but has the MoD thought through alternatives such as organising land convoys to Kuwait and using civil aircraft from there?
	The progressive increase in the level of violence on all sides suggests that we do not have our strategy right. The UK forces will do their best, but there is a danger of escalation without end. After the freezing out of the United Kingdom from US planning during the Coalition Provisional Authority period, can the Minister assure your Lordships that the US is now listening to the United Kingdom's advice? Can he offer some prospect that the different counter-insurgency doctrines of the various forces currently in Iraq will be harmonised to make for a more coherent approach.
	Finally, will the Minister ensure that the long-term viability of the British Armed Forces remains one of his key concerns in planning future operational tasks and the funding of the equipment programme?

Lord Drayson: My Lords, I thank noble Lords opposite for their constructive criticism of our activities in Iraq. I know they share our desire to see Iraq develop into a stable democratic anchor within the Middle East. The issue is how best to achieve that.
	I turn to the specific questions, and start with the last one from the noble Lord, Lord Garden. My reply is: absolutely. In everything I do, my focus is to ensure the long-term viability of our Armed Forces.
	How do we define the job? It is clear that our task is to move forward to an environment where the political control of Iraq is under the Iraqi people; to move forward to the point where the Iraqi security forces can take responsibility for their own security in order to protect and serve the democratic government; and to move forward to the point where the improved economic and social development of Iraq is absolutely clear so that the benefits of democracy are clear to the Iraqi people. Those are objectives for which there is no rigid time-line. It is not helpful, as I think was said recently by President Talabani, to set out a rigid time-line. That plays into the hands of the people we are fighting. We have set out clear conditions under which we will be able to withdraw and that is as far as we can go.
	The roulement into Iraq which will take place shortly will slightly decrease the number of forces to about 8,000 after the reserve force has returned. We believe that that is the appropriate level, taking into account the recent handover of a number of camps to Iraqi control, including, for example, Camp Chindit.
	The noble Lord mentioned the Royal Highland Fusiliers, who have been stranded in Jordan, and the general point about troop transport. We recognise the vital importance to morale and not least to our operational capability of being able to move our troops. The Tristar aircraft which we use are old and it is very important to replace them as soon as possible. We have had operational difficulty, as the noble Lord mentions, with defences on the aircraft. Of course, we will take no risk with our personnel in those transfers. However, I am pleased to report to the House that the issues relating to those aircraft have now been resolved and that there are no stranded forces as a result. We are working hard on this issue and I am spending a lot of time on it.
	Noble Lords mentioned the issue of helicopters, which are absolutely essential to our ability to function fully in Iraq and in other theatres such as Afghanistan. We have enough helicopters, but they carry a significant burden—a matter to which we are giving significant attention. In early September we increased the number of helicopters available in theatre in Iraq.
	The noble Lord mentioned particular devices, possible Iranian involvement and the action we have taken. We have seen such devices before, and this experience indicates their source. They are similar to devices that have come from Hezbollah. That concerns us, but further work needs to be done in this area. As I said, we have come up against such devices before.
	I have seen for myself our excellent capability in countermeasures. Of course, I cannot go into further detail, but I can reassure the House that we are fully on top of that.
	On the Attorney-General's visit to Iraq, noble Lords will understand that, for security reasons, we do not comment on the movements of senior personnel, but I take on board the points made by the noble Lord in his letter. I will follow them up and write to him. On contingency plans for rejection, it is clear that if the Iraqi people so decide in a referendum on a no vote, we move forward within the period under the transitional law. It will then be up to the assembly to advance future consideration of a constitution.
	I am not able to discuss the detail of operations. In the Statement, we described the roulement of forces and the forces that will be going to Iraq in an exposition, but it is not appropriate for me to get into the detail of what is the relative balance of those forces or types of operation. It is true, as the noble Lord mentioned, and as the Chief of the Defence Staff commented, that Iraq is having an effect on recruitment. However, we are working hard on that; we need suitable action in place; we are not complacent about it. We recognise an issue in that area and are working on it.
	Going further on the question of air transport, the noble Lord asked whether the Ministry of Defence has alternatives when we have problems with our Tristar aircraft. Yes, of course we have alternatives. The problem in this case was that our alternatives involved the use of chartered aircraft. We could not obtain democratic clearance in the timescale we needed for those chartered aircraft to pass through the required countries. Therefore, we judged it better to focus on fixing the technical problem relating to the aircraft concerned.
	We have a coherent approach. We have clear contingency plans for the situation that we face in Iraq. As I said earlier, we believe that, whereas the situation in Iraq is challenging, our forces are on top of it. We focus on long-term viability in our planning of operations; the recent roulement that we announced today reflects that.

Lord Drayson: My Lords, the noble Lord makes a very important point. However, morale does not seem to be affected, which underpins the commitment that the Iraqi people have to the progress that they are making. There is no shortage of people wishing to join the Iraqi security forces, particularly the army. Nonetheless, we are, of course, doing everything that we can. We are supplying equipment and giving training and mentoring to those forces. We are passing on experience that we have gained, for example, in previous operations in Northern Ireland, in order to do everything that we can as regards tactics and equipment to overcome the threat presented by roadside bombs.

The Lord Bishop of Oxford: I very much respect the serious intentions of the noble Lord, Lord Joffe, and the care that he has taken with the Bill to try to limit any possible damage. I should also like to say to the Select Committee, as a person who was not a member of it, how valuable the report was. It was a model of clarity and helpfulness.
	It has been suggested or hinted a number of times that the main arguments against the Bill are on religious grounds. There are some religious arguments, and it may be that some of them will strengthen arguments of another kind. But I know that the right reverend prelates the Bishops of St Albans and of London, and myself, believe that these are rational arguments that can be considered by rational people whatever their religious views.
	A leading article in the Guardian this morning said that the bishops,
	"should be listened to with respect—and then ignored".
	I feel like writing to the Guardian and asking if it would please assess the rationality of our arguments. That is very much what I hope your Lordships will do.
	I believe that there is a fundamental philosophical flaw behind this Bill which, indeed, would be behind any successor Bill. It concerns autonomy, which cannot be taken as the overriding principle. In some respects all noble Lords would accept that. But Professor John Harris, who has been very influential and been quoted in the Select Committee report, stated:
	"It is only by the exercise of autonomy that our lives become in any real sense our own. The ending of our lives determines life's final shape and meaning . . . when we are denied control of the end of our lives, we are denied autonomy".
	What worries me about that quotation is that there is a sense that if we are denied autonomy—the ability to make a choice at the end of our lives—our lives somehow lose shape and meaning. I suggest that our lives have just as much shape, meaning and value when we are in positions of total dependence on other people. For much of our lives we are dependent on other people and may not be capable of making significant choices at all—in the womb, as a child, through periods of sickness, and perhaps for quite a long period at the end of our life. A loss of autonomy does not signify any loss of meaning or value from our lives.
	Here, we need to face the fact that, as was once put rather brilliantly, mind is a social reality. We become persons in relation to other persons. There is a western idea that has been with us since certainly the 18th if not the 17th century: we are essentially human beings only if we are standing on our own and making heroic choices. That is a totally flawed understanding of what it is to be a human being. We are interdependent, there is mutuality, and our meaning and value are discovered just as much through other people's attitudes to us when we are dependent as they are in the choices that we make.
	I know that the noble Baroness, Lady David, felt rather insulted by the reference to people with strong personalities wanting to be in control of their lives. I point out to the noble Baroness that that was in the Select Committee report as evidence of the kind of people who are seeking this measure. In contrast to that, we need to pay attention to the point in our lives when we are dependent on others. We should realise that at those times we in no way lose meaning or value.
	There is time for only one other point, which is in reference to the well-known "policeman's dilemma". A motor accident leaves a lorry driver trapped in his burning cab. He cannot be freed and he asks a policeman to shoot him before he agonisingly burns to death. Many of us here—I am certainly one—would not judge a person in that situation to be wrong. But Professor Harris says:
	"If we concede this case, then we concede the principle of assisting death in extreme distress and where the condition, as the lorry driver's was, is clearly the terminal one".
	I do not believe that to be true. There are certain boundary situations where agonising choices have to be made. There are certain exceptions. But you cannot take from those exceptions general principles of prescriptions and laws. St Thomas Aquinas gave a well-known example. He said that if a person who is starving to death steals when there is no other way of obtaining food, he is not guilty of theft. That is a similar boundary situation but we would not dream of legislating for that. The fact that we concede the policeman's dilemma should not bemuse us into thinking that we should therefore legislate. The point about exceptions is that they really are exceptions, and we do not want to legislate for them.

Baroness Gibson of Market Rasen: My Lords, I, too, congratulate the noble and learned Lord, Lord Mackay of Clashfern, and his committee members on their well-balanced report.
	There is no doubt that those who support and those who oppose the Assisted Dying for the Terminally Ill Bill introduced by the noble Lord, Lord Joffe, hold genuine and sincerely held views upon it, and that, as usual in your Lordship's Chamber, the debate is being conducted with respect for each other's views.
	Many of us know people who believe their lives to be painful beyond tolerance, and we all wish such suffering to be alleviated. Where we are divided is on whether, and how much, help should be given to terminally ill people to end their lives, should they wish to do so. I put my name down to speak in this debate before our long summer break began. I believed in the proposals in the Bill then and I believe in them now.
	During the summer, a number of events strengthened my support for such legislation. I watched a television debate on the Bill. An intelligent and articulate woman, with an equally intelligent and articulate brother, explained why she helped him to die peacefully and, as they put it, with dignity. A key reason was that the brother, whose intellect remained, was slowly losing his ability to articulate, and his misery and frustration at his illness and loss of faculties was almost tangible through the television set.
	The brother and sister travelled abroad to achieve his aims—to end his life in what he described as a dignified manner at a time of his choosing with those he loved most with him. His quiet determination shone out of the film that the family had made of his illness and of the decisions he took about it.
	Almost on the same day, I received a letter from a young woman with a terminal illness. Indeed, it may be the same letter as that received by the noble Lord, Lord Russell-Johnston, who mentioned it in his speech. The young woman is 28 years old and has heart and lung problems, causing her to deteriorate slowly. She uses oxygen constantly and is severely physically limited. She has been told that she will continue to deteriorate. She wrote:
	"Because the current law forbids assisted dying, I have had to make the decision to starve myself to death. This could take some time and may cause even more physical pain. I have, however, come to the conclusion that starving myself to death is more favourable than living as I do".
	She does not want to travel abroad; she wants to die in her own country. She pleads with us to listen to our public and to hear their voices. The Bill, which is the subject of this report, would allow her to die in the way she wishes at a time she chooses. I do not believe that we have a right to deny her that.
	I also received a moving letter from a young woman about her father's death. He had wished to be helped to die. She wrote:
	"Having the right to decide the time to die would give the patient control at the end and make the process less frightening because the terminally ill person is the only one who knows when he or she wants to pass away. It is their perception of dignity which is important".
	I believe that that is true.
	Obviously I have received letters both for and against changing the legislation, as I am sure we all have, from individuals and associations, and I shall mention just one or two. I was particularly grateful to the BMA and the GMC. They both clearly set out their stance on future legislation, which in both cases is neutral. I had heard from doctors for and against the proposed legislation, with both sides claiming the backing of the BMA and the GMC, and so I was relieved to have this issue cleared up. I understand that both organisations have said that, if such a Bill became law, they would be able to publish guidelines to underpin the practice.
	A further letter came from the disability committee of the National Union of Students. The committee members are elected representatives of students who have various disabilities, both seen and hidden. They support such a Bill, believing that it will protect vulnerable disabled people more than the current law does. On the other hand, RADAR, for which I have a great deal of respect and with which I have worked in the past through my work at my union, Amicus, sent a very thoughtful briefing in which it explained why it cannot support the introduction of the proposed legislation at this time. But it stressed the need for better and increasing palliative care—a point with which I agree wholeheartedly.
	As do others in the Chamber, I believe in the expansion and extension of palliative care. I believe that those who choose to receive it must have the best treatment possible and that equitable access to palliative care for all should be provided. That is in line with the response of the National Council of Palliative Care to the report on the Bill. I differ from the NCPC in that I do not believe that this must be provided before pursuing assisted dying for the terminally ill. It is possible to press for better palliative care at the same time as allowing the assisted dying option for those who choose to take that route. Palliative care and assisted dying are not mutually exclusive. Both are needed, and should be allowed.
	Finally, I am sure that if a new Bill is introduced, it will be discussed in depth in this House. I am also sure that improvements will be made during those discussions and amendments. I support the noble Lord, Lord Joffe, in his efforts to bring forward well-constructed legislation in this difficult area.

Lord Gilmour of Craigmillar: My Lords, we have heard strong speeches on both sides. I shall look briefly at the arguments against the Bill.
	The strongest argument against the Bill, of course, is that assisted dying may enable jealous and tiresome relatives, or others, to persuade old people to agree to be killed because they think that they have become an intolerable burden to their children and friends. However, the Bill provides stringent safeguards against that happening. It has not happened in Oregon, as my noble friend Lord Arran made clear, and, as the noble Lord, Lord Taverne, said, it has not happened in Holland. Moreover, the Joint Committee on Human Rights decided that the safeguards in the Bill were adequate to protect the vulnerable.
	Secondly, there is the slippery slope argument, which maintains that, if the Bill is passed, all sort of dreadful Bills or actions will be passed in future. We are always on the slippery slope; it is not necessarily a bad slippery slope—it may slope in the right direction. The slippery slope argument has probably been used against almost every measure for some 200 years. It is often a favourable slope, as the history of the Reform Bills in this House well shows. In any case, the view that we should not do the right thing today because somebody else may do the wrong thing tomorrow is surely not a compelling argument.
	Then there is the argument that committing suicide, or helping somebody to do so, is wrong because of the sanctity of life. Since 1961, however, suicide has not been illegal—though assisting suicide is, of course. If the terminally ill person is incapable of doing what he wants because of the illness, however, different considerations should surely apply. The sanctity of life is a difficult concept. It is evidently not known or followed by Messrs Bush and Blair, who are killing thousands of innocent civilians in Iraq. According to President Bush, it is not even known to God, since God told him to launch the invasion.
	The idea that it is God's will that an old and weak person should spend a month or so dying in agony and dissolution, to the anguish and distress of his family, rather than being allowed to die with dignity a few weeks earlier as the result of an assisted suicide seems extraordinary to me. The most reverend Primate the Archbishop of Canterbury and the right reverend Prelate the Bishop of Oxford put that argument separately in the papers on Sunday—the right reverend Prelate put it again today—and it seems explicit in both articles. I quote the article of the right reverend Prelate:
	"a person in extreme distress as a result of a debilitating illness is in a very different situation. But does their life not still have value? Do we not want to say to them: you are still of worth, we still want you with us, we don't want to empty our lives of your presence?".
	If I were in a state of terminal illness and extreme agony and somebody came along and said that to me, I hope that I would convey my displeasure—I probably would not be well enough to hit him—and make him leave that room pretty soon. It seems to me to be well beyond the reach of any form of reality, although, as the right reverend Prelate said, it may still be rational.
	We know that doctors, hospitals and nurses allow terminally ill people to refuse life-preserving treatment or drugs, a practice that the most reverend Primate the Archbishop of Canterbury supports. The fact that that is permissible but that doctors are not allowed to administer a drug or medicine that will kill patients quicker and more mercifully is equally extraordinary and reminds one irresistibly of the famous words of Arthur Hugh Clough:
	"Thou shalt not kill; but needst not strive,
	Officiously to keep alive".
	I appreciate, of course, that some doctors have strong views and would not want to participate in any such process. They should obviously be allowed not to do so. Other doctors would do the job, and their feelings should be respected.
	The arguments against the Bill introduced by the noble Lord, Lord Joffe, do not stand up. I strongly support it.

Lord Phillips of Sudbury: My Lords, I thank the committee for the wonderful report that it has produced, and the noble and learned Lord, Lord Mackay of Clashfern, for his chairmanship of it. Beyond and above that, however, I thank the noble Lord, Lord Joffe, for the hugely important role that he has played in bringing this most important of subjects before the House and the public, his indefatigable pursuit of the issues and his sensitivity to views other than his own. I cannot speak too highly of what he has done.
	I am a solicitor very long in the tooth. I have had nearly 50 years in the profession. At different times in my career, I have dealt with old and frail people, both in the making of their wills and acting as an executor of their estates, dealing with applications to the Court of Protection. I spent four years as a coroner's assistant, an extremely educative phase of my life, where you come very close to the realities of what we are talking about. I am going to make a few practical observations.
	My first is that legislation is never better than a crude instrument. We deceive ourselves if we believe that we can load on to the shoulders of legislation all the refinements and subtleties that we would wish to see in legislation allowing assisted dying. It cannot be that subtle or calibrated.
	Modern legislation, I suggest, is honoured in the breach: 14,000 pages of new statute law a year, most of it remaining on the shelf. What is implemented is implemented unevenly and with undue discretion on the part of those enforcing it. How can we be sure that this most complex legislation would have the quality of enforcement and policing without which it could be wholly counterproductive?
	The evidence from Oregon and Holland has been presented to us by several speakers as justifying the proposed legislation. I cannot see that. The law was changed in Oregon only in 1998 and in Holland in 2001. The most important aspects of the evidence that I would want to see are the most difficult to find. For example, there is the whole question of undue influence or pressure on old people from relatives, beneficiaries and the like: how does one go about getting evidence for or against that? I suggest to your Lordships' House that we are not remotely in a position of having adequate evidence one way or the other.
	The draft Bill itself is full of ambiguities and flexibilities. I do not blame the noble Lord, Lord Joffe, and his helpers for that because we have a cruel choice in legislation. You either have something that is so fixed and certain that it is inflexible or you have something that, being flexible, is full of movement and ambiguity. I pick out a few such key words: "capacity"; "competence"; "fully informed"; "temporary relief". At the heart of the Bill, is the phrase "a few months". "Unbearable suffering" is defined as,
	"suffering whether by reason of pain or otherwise".
	There is no suggestion of what "otherwise" that might be. All that would lead to a position that we have seen pursuant to the Abortion Act: specialist firms of doctors offering their services as an assurance to find a way through the complexities to the result that an old person or, more likely, the relatives wanted.
	Above all, we cannot have it both ways in the Bill. We cannot liberate the terminally ill suffering unbearable pain—in the way that, I understand, people want—and simultaneously protect the vulnerable old from abuse by pressure or undue influence. We cannot straddle those dual objectives. There will be the age-old problem of people saying, "I'm a burden on my family. I've had a good life. I can't afford it". That is a commonplace, and we have all seen it. I am afraid that, whether one wishes for it or not, undue influence will be the necessary handmaiden of the Bill, however unintended.
	In Oregon, the research by A D Sullivan and others shows that, whereas in 1998 only 12 per cent of those requesting physician-assisted suicide felt themselves to be burdensome, a mere two years later that had risen to 63 per cent. In the 1987 MORI survey annexed to the report, 71 per cent agreed and only 12 per cent disagreed that people permanently dependent on others for medical or nursing care might request euthanasia in order not to be a burden on others. Even among geriatricians, a survey done by the universities of Sheffield and Charleston in 1999 shows that 84 per cent of them believe that legalisation of patient-assisted suicide might put pressure on vulnerable patients to request just that, and 53 per cent feared that the social process of dying and grieving might be undermined.
	The balance of harm has not been weighted sufficiently for my practical view in favour of the proposed Bill. Lastly, I would call into my speech the words of the right reverend Prelate the Bishop of Oxford and my noble friend Lord Carlile.

Baroness Morgan of Huyton: My Lords, when people ask what the point of the House of Lords is, we should point to this debate and to the quality of the committee's report. Whatever the eventual outcome of our discussions—I should say that I support a change in the law—the time is clearly right for this debate. I pay tribute to the noble Lord, Lord Joffe, for bringing forward his Bill.
	We cannot ignore this matter because it is being debated in the country, in the media, in pubs, in churches, at school gates, over the kitchen table and in many families. The public followed the Diane Pretty case in detail day by day and watched its tragic outcome. This is an issue that touches, or will touch, many of us. It is not the preserve of professionals, nor can it be the preserve of those with strong religious beliefs. It is the preserve of all of us.
	We have received particularly strong statements from practioners of palliative care and from hospices that their relationships with the terminally ill could be affected. Of course we have to listen to and respect that. But we should recognise with the greatest respect that their views may not be the views of their patients. It is their patients' views that must be paramount. The Bill offers independent choice to those who are denied it at present. Of course we all wish to see palliative care improve in future and hope that the Bill will not be necessary. But the Bill does not deny the improvement in care that we all seek. This is not an either/or situation. This is an issue of independence and equality. It is about an extension of human rights to those who are at present denied them.
	I welcome the amendments outlined today by the noble Lord, Lord Joffe. They deal with several concerns raised by the committee. It is clear that a lot more detailed work will be needed to get the Bill right. But in the end the public know in principle what this debate is about. Like many noble Lords, I have received lots of strongly argued letters with passionate views from both sides. Like my noble friend Lady Gibson, I found one particularly poignant and I shall read a section of it. The young woman argues that she has a very cruel choice between starvation or hard suffering and a very unpleasant end. Her other choice is to go abroad with her husband to help her. The reason that she feels unable to do that is her fear of what her husband's legal position would be when he returns. She wrote:
	"I cannot plead with you more, to listen to your public. Hear their voices. A change in the law to make assisted dying legal in this country is not only the right decision, but also a necessary step forward, so that people, who often have their dignity taken away from them by their illness, can at least have a dignified death at a time of their choosing. Bring an end to the unnecessary suffering felt by many. Given patients their voices back".
	I hope that we can fulfil her wishes so that in future others will not suffer in the same way.

Baroness Warnock: My Lords, it has become abundantly clear from all that has been written spoken on the subject of today's debate that there are two different kinds of argument against what the Bill would permit. The first is absolutist and the second is consequentialist. We have not heard very much about the absolute argument this afternoon. I shall say very little about the consequentialist arguments. They focus mainly on the slippery slope, at the bottom of which lies non-voluntary euthanasia, or they concentrate on the supposed fact, which I by no means accept, that the passage of the Bill would mean an erosion of trust between doctor and patient. These are empirical arguments, based on what is thought likely to happen. As such of course they ought to be based as far as possible on evidence.
	I want to concentrate instead on the absolutist argument that it is morally wrong to allow assisted death for those who seriously request it because it would violate the principle of the sanctity of human life. That issue has already been mentioned and came out very well in the quotations that we were referred to by my noble and learned friend Lord Ackner. Those whose objection to the Bill is based on this principle have no need to invoke the consequentialist arguments against it, although they often do—and although it may well be true that, as the right reverent Prelate the Bishop of Oxford said, many in the Church actually rely more on the empirical than on the absolutist arguments.
	It is clear that most people—I would say everyone in your Lordships' House—believe that human life is a value that has enormously high priority among all the things to which we attach value, and that one must be extremely cautious in giving other values priority over it. But those who literally believe in life's sanctity, argue, as the Church of England and the Roman Catholic bishops and the Chief Rabbi did in their written submissions to the Select Committee, that this sanctity derives from the fact that:
	"God himself has given to humankind the gift of life".
	Or, in the more explicit words of the Chief Rabbi, that,
	"life is a precious gift from God . . . whose value is absolute and not relative to factors such as age and health".
	That was the fundamental basis on which those men of God founded their evidence to the committee.
	I want to suggest to your Lordships that, in matters of legislation especially, it is crucially important to distinguish moral arguments from religious or theological arguments. That is true despite the undeniable fact, which I certainly would not deny, that our morality has been hugely influenced by the Judaeo-Christian tradition. But the law cannot be based on the literal interpretation of religious beliefs of some, but not all, Members of Parliament, or of some, but not all, members of society. There are many people, even many people who, like me, are church-goers, who cannot take literally the proposition that being God's gift confers on human life a special sanctity regardless of its quality and regardless of whether the person living it wishes to preserve it. Life is not an abstract thing; it is not a separable non-concrete entity. A human life is always being lived by somebody. Someone in the extremity of suffering, knowing that his life is in any case drawing to a close, and begging to be allowed to die, will not be comforted by the thought that another person, not he, places the value of his life above every other conceivable value. And indeed, he may wish, as has been pointed out, to point out that we do not always apparently regard human life as having to be preserved at all costs. Not everyone, as the noble Lord, Lord Gilmour, suggested, who is opposed to this Bill has refused to sanction the deliberate sacrifice of human life to other values in time of war, for example. I would argue that in certain limited cases, as outlined in the Bill, we should forget the theological arguments defining life itself as possessing an intrinsic sanctity. I turn instead to that separate moral argument; namely, the argument from compassion.
	Compassion will of course lead us to try to make any human being's life when it is coming to its end as tolerable as possible. But by any moral standard is it good to prolong that life against his express wishes? Is it better by any moral standard to keep him alive if in some extreme case he is reduced by our efforts to actual unconsciousness, rather than to allow him to decide that now is the time to go? I cannot myself regard this as a rational or defensible morality, upon which the law must in my opinion be based.

Baroness Knight of Collingtree: My Lords, I, too, begin with a tribute to the Select Committee, which did a difficult job extremely well, but there can be no doubt of the validity of the comments of the National Council for Palliative Care in its responses to the report. It says that much more evidence should be sought and lists eight crucial areas that have not been properly examined. Even one of those eight could be enough to stop the Bill in its tracks.
	Euthanasia seems quite cosy and humane when it is first suggested: "Let's stop suffering. Let's get doctors to help us out of this vale of tears when things get rough. We put down dogs, cats and horses. Why not humans?". Humans are not dogs, cats or horses. Doctors are not killers. Suffering can be ended without ending life. In Oregon, where euthanasia is legal, palliative care is now regarded as unnecessary. What about that for a slippery slope? Apparently, in Oregon, they do not bother to make palliative care available at all—because killing is.
	The more evidence that one receives and the more thought that one gives to the actuality of euthanasia, the more one turns against it. Certainly, legalising it puts elderly and helpless people at terrible risk. They know that, which is why so many of them are afraid of what our conclusions may be. Some people say that doctors already kill and have done so for years. Where is the firm evidence? Surely we can all agree that there is no more grave matter than bringing about the death of a human being. Hearsay evidence is not enough when deciding whether, how or in what circumstances killing should be allowed. Not nearly enough is known about palliative care, the extent to which suffering can be contained or how advances in medical techniques and expertise are changing and improving life for sick people all the time. Surely, it is far better to recognise and encourage research into all of that, rather than to forget it and kill people, as is happening in Oregon.
	There has been no attempt to answer fears that the Bill could lead to the widespread killing of people who have neither asked nor wanted to be killed. The evidence from Holland shows another slippery slope that has been slipped on well and truly. Surely, no one can say that it has been in a good direction. Doctors in Holland openly admit that legalising euthanasia has led to the killing every year of 1,000 people who never asked to be killed. That may save money, it may empty hospital beds and it may get rid of troublesome people, but, unless Harold Shipman was right, it is wrong. No wonder more than 10,000 people in Holland now carry cards in their wallet saying, "Do not kill me".
	Something else is very sinister in the Dutch law, and we have not heard about it yet: it permits children aged between 12 and 17 to ask for euthanasia and to get it. That cannot be either ethical or logical. As many of your Lordships surely know from experience, teenagers are often plunged into moods of black depression by the most trivial things: a football team loses, a love affair goes wrong or an exam is looming. "I just want to die!", they wail. To take them at their word is wicked. To allow such children to be legally killed when they have their whole life ahead and have no experience of how wonderful life can be and no understanding that all disasters end is wrong. They are often immature, emotional and sad little souls who need love, care, help and hope—not death.
	We should look more closely at how legalised euthanasia is working elsewhere: at the many examples of the dangerous slippery slope that it opens up; at the denial of human rights that it involves and the terrible fears that it heralds. Nowhere in either the report or the Bill can I find any surety that we could avoid the experience that other countries have faced before us.
	Finally, I worry that doctors who fundamentally objected to killing their patients would be forced to do so or would have to leave the profession if the Bill were passed. The Select Committee worried about that too. How could such doctors be protected? In this country, we have huge numbers of Muslim, Hindu, Christian and other doctors whose faith directs them only to cure. We could not staff either GP surgeries or the hospital service without them. How can we pass a law that would give patients the right to a procedure that so many doctors object to carrying out, while giving doctors the right not to carry out that procedure? Will we have official lists of doctors who will kill and those who will not? Oh, please not.

Viscount Craigavon: My Lords, I strongly support this prospective Bill and warmly congratulate the noble and learned Lord the chairman and his committee on producing such a report, one that enables those who want to do so to understand all sides of the present debate. The report and, in particular, its volumes of evidence, make up a valuable and readable account of where this evolving debate has reached. The changes it highlights since the 1994 Lords report on medical ethics are stark.
	I shall touch on just a few aspects that seem important to me. Various opinion polls have been quoted and put into context, but I should like to emphasise the very recent Daily Telegraph YouGov poll which showed what was called huge popular backing for legislation for assisted suicide. Some 87 per cent of those questioned agreed with the statement that people who are terminally ill,
	"should have the right to decide when they want to die and to ask for medical assistance to help them".
	That is a trend and direction in public opinion which should be taken into account even if the exact figure might not be accepted. Reading it in the Telegraph makes it even more persuasive.
	We should be grateful that the various royal colleges and societies seem to be moving from a monolithic view to reflect that in practice their members tend to be significantly divided. In my opinion, there is no loss or shame in that. We should welcome this relatively new attitude taken by these various organisations which, in necessarily different ways, have allowed themselves to be much more neutral in this debate. Reading their oral evidence is almost essential in order to understand the rationale and nuances of their position, although I realise that not all the colleges have changed and that they all have slightly different remits.
	As has been mentioned, one of the key concepts influencing this is "patient autonomy". The Select Committee report provides throughout a great amount of detail on how in practice this is balanced in making decisions. I hope that anyone trying to relegate the importance placed on patient autonomy in this context will first at least have read the extensive evidence in the report. Indeed, the speech of the right reverend Prelate the Bishop of St Albans sought to set up what was almost a straw man in order to knock him down, while the speech of the right reverend Prelate the Bishop of Oxford was a slightly more sophisticated version of the same. At the very least, patient autonomy should allow for some form of feedback from the patient. I was under the impression from both the right reverend Prelates that whatever the patient said would not be taken into account because they had a better and more authoritative idea of what would be good for him.
	We have been told that the recent remarkable BMA decision and vote was completely within its rules. As has been said, the BMA's decision is,
	"not to oppose legislation which alters the criminal law, but should press for robust safeguards for patients and doctors who do not wish to be involved in such procedures".
	Whatever pleadings are made about the figures of the vote, it is a remarkable change of attitude.
	I realise that the different organisations collect and report on the views of their members in different ways. I read the oral evidence of the Royal College of Nursing, to which the noble Baroness, Lady Thomas, also referred when making a similar point. Some members of the committee asked the representatives to justify why they were reporting as official policy their "collective" and what were called "themed" views against the thrust of the Bill when it was held to be known that a significant proportion of their members might not agree with that position. I understand that my noble friend Lord Joffe, despite being given assurances of further information and figures from the RCN about the basis of its claimed "themed" position, has still received nothing. One can only guess that this is the way it chooses to show so-called "leadership" to its members.
	Another, alternative voice on this subject in the report comes from a nurse. It is set out on page 95 in Volume III. The nurse, the elected chair of the RCN Ethics Forum Steering Committee, submits a most reasoned submission; one made, as she rightly has to say, in her personal capacity. She states that she believes that,
	"the submissions received during the RCN's formal consultation process were overwhelmingly in favour of changing the law".
	In the first sentence of her conclusion she states her belief that:
	"The vast majority of UK nurses support assisted dying for the terminally ill".
	Whatever the percentages on either side, I believe that the present RCN approach is counterproductive.
	Finally, perhaps I may point out a slight paradox. We are told by opponents of this Bill that the uptake of what might be available is likely to be on a considerable scale. Given that the nearest parallel will probably be the Oregon system, if I may use rather round figures, it is remarkable that out of around 30,000 deaths a year in Oregon, about 60 people are given the prescriptions they request and only 40 actually use them. On such a scale, that is not likely to cause a major change or upset in our attitude to death. The significant proportion of people who ask for the option but then do not use it points to the additional benefit for an even larger number who have the reassurance that a "back-up" system is there and is available to be called upon if they need it. That is a recognised phenomenon and was described very well by the noble Earl, Lord Arran.
	When my noble friend Lord Joffe brings back his revised Bill, I strongly hope that this House will follow the recommendation made in the committee's report that it should have a formal Second Reading before going before a Committee of the Whole House, where I sincerely hope that we can have a rational and considered debate on the details of the Bill.

Baroness Howe of Idlicote: My Lords, I join other noble Lords in congratulating the noble and learned Lord, Lord Mackay, and his committee on such a knowledgeable and balanced guide to this very difficult subject. No one who heard the dramatic and sad account of the noble Lord, Lord Puttnam, could be other than sympathetic and very concerned about the conditions in which those whom he described died. However, if the Bill introduced by the noble Lord, Lord Joffe and not the Select Committee report were before us today I should be unlikely to support it.
	Apart from the concerns of the healthcare professions, to which I shall return, my reasons for caution fall mainly into the "slippery slope" category, which I think both exists and is very relevant. There is also the risk of masking the need for a huge improvement in the availability and quality of palliative care for those with terminal illness.
	On the slippery slope concept, I am concerned that such a Bill could all too easily increase the risk of legalising assisted dying and euthanasia well beyond the three currently named qualifying groups. The report rightly draws attention to the need for those categories to be much more clearly defined, but would that be enough?
	There are, I fear, also some economic factors at work. We are an ageing population, and that means higher costs as well as benefits. Most citizens have little need of healthcare so long as they are young and healthy, but when and if they reach the point of being unable to care for themselves they deserve proper and, above all, pain-free—I insist on that—and, inevitably, increasingly expensive healthcare. Yet we know that they do not always get it. Indeed, far too often they do not get it.
	Inevitable pressures exist—have always existed—on NHS budgets. Concern about delays in securing rapid enough approval for the latest cancer drug, about which we have heard over the past month or so, is just one example. The postcode lottery aspect of whether the health services needed are available in your area is another. So I share the concern, for all those reasons, that the basic human rights of the elderly and other vulnerable groups could all too easily slip still further down the priority list.
	I turn now to the concerns of the caring professions. There is, rightly, much discussion of the role and responsibilities of doctors. That is entirely reasonable, for they are the people who would be prescribing lethal drugs or administering lethal injections. As the Select Committee made clear, hospital doctors would bear the main burden of euthanasia requests. Even so, I was disappointed to see how little emphasis there was in the report on the position of nurses.
	Many years ago, I served on the commission, under the distinguished chairmanship of the noble Lord, Lord Briggs, on the future of the nursing profession. Its membership included every kind of medical, nursing and manpower expert. Being none of those, I gave myself the title of "Patients' rep", and from the patients' viewpoint, and in so many other ways, I came away with a profound admiration and respect for the nursing profession.
	In the context of this report, nurses, in some respects, occupy an even more central position than doctors. They are generally the member of the healthcare team to whom patients feel most able to speak freely; they are usually with the patient all the time. The doctor, by definition, is generally a visitor and, albeit under the doctor's supervision, the continuing burden of patient care falls inevitably on the nurse. Of course, it is exactly the close relationship which develops between patient and nurse that is so critical in today's debate.
	As the RCN has pointed out,
	"there is a real danger that the proposals in the Bill could undermine the nurse-patient relationship, leading to a culture of fear amongst vulnerable people at a time when they most need to feel supported by their clinical team".
	Many of your Lordships have raised that point. Yet, despite that, nurses seldom appear in the noble Lord's Bill either. Almost the only reference to the nursing profession is the general phrase "member of a medical care team". That is a serious deficiency.
	Finally, let me say a word about palliative care—others have touched on it as well. The Bill would enable an applicant for euthanasia to ask for a palliative care consultation, but, as the committee wisely observed, experiencing good pain control is different from being told about it. To have reached the despair of requesting euthanasia, a patient is likely to have received inadequate care and to be completely worn down, unable to conceive of anything that would really improve quality of life. It is therefore insufficient for any Bill that purports to see palliative care as complementary to euthanasia simply to offer the option of a consultation. We should not agree to end the life of patients who have not experienced good palliative care.
	All that begs the question: why have those dying people not received good care? After all, the report tells us that Britain has the best palliative care in the world, so why are people still dying in despair? The answer, I fear, is simple. As with so much else in the NHS, Britain leads on quality but is deficient on quantity and, sadly, distribution. Up to now, the gap has been filled, to a large extent but by no means sufficiently, by the voluntary sector's Herculean efforts. Where there are specialist palliative care centres, as has been so brilliantly argued by my noble friend Lady Finlay, and doctors and nurses who have had specialist training, the ability to alleviate the suffering of terminal illness is little short of dramatic. The problem is that such centres of excellence are too few and far between, with the result that many people who are dying do not receive the end-of-life care that they deserve. Yet, we are debating assisting patients to commit suicide or giving them euthanasia, when, with some reallocation of NHS resources, we could solve the problem without changing the law and putting people at risk. Would it not be much wiser to concentrate on that vitally important second alternative.

Baroness Flather: My Lords, in spite of the dismissive way in which my noble friend Lady Knight spoke of dogs, cats and horses, I submit that in this country we adore our pets and give them the best care possible, we tolerate our children and are not that bothered about older people. The culture I come from is not quite the same. Older people are respected and cared for by the younger people, children are ever with the family and pets take a very low position. In this country, we spend money on pets and take advice from vets. If we want to keep a pet alive against a vet's wishes, we are told that we are being selfish. Yet we do not want to allow a person who can ask for help to have it. We do not want a person who is capable of making his or her wishes known to be allowed to do so. I find that very strange indeed.
	We have heard a lot about the Netherlands. Different people have spoken about different things. I worked with a very good friend from the Netherlands who in the very early 1990s told me that her father was very ill. When I said "You will have to go and see him frequently", she said that she had met with her sisters and brothers and that they had decided that their father should have an early termination of life. In the Netherlands, euthanasia was practised before the law legalising it existed. When the law was introduced in 2001, it was not the first time euthanasia was used. I am sure that my noble friend Lord McColl will talk about his experiences in the Netherlands when we served on the committee chaired by the noble Lord, Lord Detchant.
	The situation in the Netherlands is very strange: they were practising general euthanasia, not voluntary euthanasia, long before any law came into being. They are now moving back towards regularising the position. That is a fact. I heard it from my friend and noble Lords will hear more about it in a while.
	It is interesting to hear from people of deep faith. It is not possible for anybody who has a deep-seated faith to acknowledge or accept that any patient should be helped to die by a family member or doctor. It is clear that if you believe in God, how and when you go must be God's will.
	I was a little surprised by the comments of the most reverend primate the Archbishop of Canterbury in the Telegraph yesterday that we were sleepwalking towards a breaking of trust between doctor and patient. I did not think that we were sleepwalking. Given the number of debates that we have had on the subject and the wonderful report that has been produced, I would not call it sleepwalking. Our eyes are wide open; some of us feel one way and some feel another way, but we are not sleepwalking. Nobody should be in any doubt that we have considered this matter personally and deeply.
	I was very much taken with Win and Jan Crew, whom I met at one of the meetings of the noble Lord, Lord Joffe. They took Mr Crew to Switzerland to die. It was absolutely amazing to see those two women, and how when you love someone, you would do that for them—but you cannot do it in this country. Having heard the speech of the noble Lord, Lord Puttnam, I do not think it can be moral to let somebody die by millimetres—I do not want to go into inches—and use the double effect. I find double effect to be hypocrisy, whether others do or not.
	This is a very personal issue. Each of us should try and put ourselves in that position and ask how we would feel and what we would want. We cannot speak for anyone other than ourselves, but many people in this country want some provision. Social legislation does not come out of the ether; it follows public demand. I congratulate the noble Lord, Lord Joffe, on being so persistent. It is very difficult to take on something as controversial as euthanasia.
	I do not think that assisted suicide is the way forward. Assisted suicide should be available if one wants it but it should also be possible to have voluntary euthanasia. As the noble Baroness, Lady Finlay, said, it can take 30 hours for a person to die after taking pills. Unless a magic pill is produced, we need voluntary euthanasia in this country.

Baroness Tonge: My Lords, I thank my noble friend for clarifying his position, but I urge him to think very carefully about it, because we would all like death by nature, but as I said earlier, a lot of people do not achieve that because other people will not let them have it. They prolong their lives unnecessarily.
	When asked whether they had had any evidence of vulnerable people being forced into receiving assistance to die, both the Oregon Medical Association and the Royal Dutch Medical Association said that they could not give any examples. The patients to whom we are referring in this regard want to maintain control over their life and death, and they can do so in Oregon and the Netherlands.
	Asked about the "slippery slope" argument, both Oregon and the Netherlands responded with demographic evidence that the law is being used as intended and that the number of people opting for doctor-assisted dying is stable and not rising. Evidence from the United Kingdom published in the Lancet a year or so ago, to which I believe my noble friend Lord Russell-Johnston, referred, suggests that there are already about 18,000 medically assisted deaths in the UK per annum. I do not know where that figure comes from, but presumably those assisted deaths are performed by doctors without any regulation or oversight. I wonder how many of those deaths were done with informed patient consent. Surely that could be the slippery slope that we so dread. It must be regulated, and the doctor-patient relationship must change, with patients being in control of their lives and their deaths, not the doctors. The Oregon Medical Association found it difficult to assess whether the new law had affected that relationship, while in the Netherlands the problem had been the number of doctors who refused the patients' request; they said that 66 per cent of requests were not met because the doctor felt that the criteria for assisted suicide had not been met.
	The problem of palliative care was another question posed. As we have heard, some practitioners of palliative medicine claim that if we had better facilities in the United Kingdom, no patient would want to be helped to die. I would argue with that. Pain and its relief is not the only issue; total paralysis is the fear of many with incurable neurological disease. The most famous cases, such as that of brave Diane Pretty, fall into that category. No palliative care can alleviate the suffering of total paralysis, being unable to speak, swallow, blink or scratch—a complete nightmare. Many patients in intractable pain would prefer not to end their days in a diamorphine-induced trance, unable to communicate with their loved ones properly and eventually succumbing to the "double effect" when their breathing fails. Palliative care is much needed for those people who want it, and the responses from the Oregon Medical Association and the Royal Dutch Medical Association—from authoritative associations—suggest that the reverse is true of the fears expressed in this House. In Oregon, task forces delightfully called "comfort teams" have been set up to help clinicians, and they say that no one in Oregon now goes without palliative care if that is what they want.
	In conclusion, many of the objections to doctor-assisted dying come from people with a political-religious viewpoint—which is fine for them, but they should not impose their view on others. Many other objections are based on anecdotal so-called evidence, which is inadmissible. We have assurances from both the medical associations that have seen the proposals in practice. We hear much about choice nowadays; terminally ill patients have a right to choose, too. Whether they choose palliative care or assisted suicide or opt to continue suffering is their decision—and they must be allowed to decide for themselves.

Lord Alton of Liverpool: My Lords, when we last debated the issue of euthanasia and assisted suicide I set out my own reasons for opposing such a change in the law, but I supported the reference of these complex questions to a Select Committee. Along with others in your Lordships' House today I should like to pay tribute to the Select Committee for the honourable and diligent way in which it has discharged its duties. I pay tribute particularly to the noble and learned Lord, Lord Mackay of Clashfern, for chairing that committee so well.
	Before considering whether we should legislate in such a controversial area surely four things would be necessary. Let me take those in turn. The first is: is change really necessary? The existing law and the General Medical Council's guidelines have hitherto provided a good framework. As my noble friend Lady Finlay of Llandaff said in her powerful speech earlier today, through the palliative care movement we can provide the answer for those who are in suffering and pain. There is no division in your Lordships' House today that where bad medical practice exists, it needs to be put right, but is this the way to do it?
	The arrangements that we have in this country are admired and commended by many. The Select Committee at paragraph 59, page 25 of the first volume noted in connection with the 2002 European Court of Human Rights judgment the court's view that our laws are,
	"designed to safeguard life by protecting the weak and vulnerable",
	and that,
	"the blanket nature of the ban on assisted suicide was not disproportionate"
	and that there is "flexibility" in our law. Nor could any justification for assisted suicide be found within the convention on human rights. So we should not be propelled pell-mell into change simply for the sake of it.
	My second criterion that I think should be met is the argument about whether there is widespread agreement on the need for change. Quite the reverse is true. There is a clear lack of public and political consensus reflected in the thorough way in which the Select Committee has highlighted the deep differences of opinion and practical difficulties—divisions that have been mirrored again during this extraordinarily moving and at times very well-informed debate that we have had in your Lordships' House today. This should make us all extremely wary of legislating in haste. Many have expressed the fear that this is a first incremental stage—a phrase used in the Select Committee report—towards widespread euthanasia; a view underlined by the opposition of, among others, the Disability Rights Commission. Many of your Lordships will have received their representations over the weekend. I am personally involved as a patron of three hospices. I know that many other noble Lords are also involved in the hospice movement. We are all very well aware of the representations that that movement has made. It is fearful that changes in the law will undermine good palliative care and the work of the hospice movement.
	Thirdly, is the medical profession demanding change? We have heard today about the BMA's neutrality. However, not everyone is neutral. The Royal College of General Practitioners, which represents some 23,000 members, says that,
	"with current improvements in palliative care, good clinical care can be provided within existing legislation and that patients can die with dignity. A change in legislation is not needed".
	The Royal College of Nursing holds a similar view. That position was tellingly reinforced in a letter I received last week from Dr. Kathryn Myers. She describes what she calls the "extremely small" number of patients who might seek euthanasia. She states:
	"My clinical experience has persuaded me that there is a far larger number of chronically ill patients who have no prospect of cure who might choose, or be persuaded to choose, Physician Assisted Suicide out of a sense of duty to their families and to society as a means of lessening the financial and emotional burden that they perceive their illness places on others".
	In other words, as my noble friend Lady Masham said earlier, doctors fear that the right to die will become a duty to die.
	Fourthly, is there political will for change? That point was made earlier by the noble Lord, Lord Carter, in his telling speech at the beginning of our debate. Successive governments and the Leader of the Official Opposition in your Lordships' House, have said that they will not provide time for this sort of legislation. The elected House would have to be convinced. The last time a comparable measure was introduced there during the time I was a Member of another place it was overwhelmingly defeated. Before going any further the opinion of the elected House ought to be sought again.
	But if these four criteria for proceeding have not been met, what of the principles underpinning the Bill? In 1994 the Select Committee on Medical Ethics, so ably chaired by my noble friend Lord Walton of Detchant, unanimously concluded that legalising voluntary euthanasia or assisted suicide would be wrong in principle and dangerous in practice, representing a grave danger for many vulnerable people. Those principles and those dangers have not been eclipsed by the mere passage of time. And what of the Oregon model of which so much has been said during our debate? Those states in America that have examined Oregon as a model have all rejected it. Professor John Keown of Georgetown University in a letter to me quotes the latest position as,
	"at least 54 assisted suicide and/or euthanasia measures have been introduced in 21 states. Not one has passed. On the other hand . . . seven states passed laws prohibiting assisted suicide".
	The professor of radiation oncology at Oregon's only medical school, Professor Kenneth Stevens, is a doctor who has specialised in cancer treatment for 38 years, yet whose views were dismissed as irrelevant earlier in the debate. He says:
	"The more I have learned, the more I realise the significant harm and danger of assisted suicide to the vulnerably ill and to society".
	He points to a profound negative shift in attitude towards the terminally ill. He says that the commitment to care has become a commitment to the option of killing, with some non-terminal patients now considering assisted suicide. He says that there has not been a single instance in Oregon of assisted suicide being used for untreatable pain, and there have been problems with safeguards and with monitoring. It was said earlier that numbers have been about static in Oregon since the introduction of the law. I have here the seventh annual report on the Oregon Death with Dignity Act, which shows that the number of assisted suicides in Oregon—though small—has increased by more than 225 per cent over the past seven years.
	With great honesty, the noble Lord, Lord Joffe, made clear to the Select Committee that his Bill is, in his words, but a "first stage" and that he would prefer to see a law of much wider application. The House should ponder deeply before endorsing such a first stage, knowing in advance the destination to which we are being invited to travel.

Lord Carey of Clifton: My Lords, debates in your Lordships' House are usually important, but that on the report of the Select Committee and its implications must surely rank as among the most crucial, as far as the most vulnerable and helpless people are concerned. In contributing to the debate, I wish to dissociate myself from the view that those of us who disagree with the thrust of the intentions of the noble Lord, Lord Joffe, have a higher view of human dignity than those who present the case for assisted suicides and voluntary euthanasia. I salute the noble Lord's tenacity and recognise his concern for individuals who wish to terminate their life at a time of their own choosing. Neither side can claim to have a complete monopoly of the moral high ground. We may disagree strongly about the issues before us, but we are united in wanting the very best for such individuals and for all those who approach the end of their life in pain, distress and fear. I felt the tug of the noble Lord's argument over several months and found the debate helpful in enlarging my understanding through some excellent speeches. The noble Lord, Lord Puttnam, was very moving, and the noble Lord, Lord Carlile, presented a very persuasive argument.
	I want to take up one short although complicated issue opened up by the right reverend Prelate the Bishop of Oxford and the noble Lord, Lord Carlile. It is sometimes alleged that people who are opposed to euthanasia as in this kind of debate are religious zealots, with the implication that people without religious convictions—the so-called majority—are not opposed to it. That is a false division. Allow me to focus on just one issue—autonomy—which has been taken up again and again. We all see it as important. You do not need religious convictions to acknowledge that legalising such acts would be a mistake.
	It is clear from the Select Committee's excellent report that those who argue for euthanasia use as their main argument the concept of personal autonomy, but, as we have seen, autonomy is a weasel word. Autonomy means making up your own rules, and in a civilised society that is not possible. Who is completely free of duties to others, and where do we draw the line where life's decisions are only ours to take? Behaviour in a civilised society is necessarily modified to take account of the interests of others, so principled autonomy should replace the individualistic version of personal autonomy. In the application of the principle of autonomy at the end of life, the choice of the right to die inevitably affects others—especially medical staff who act on your choice and those who are left behind.
	It may surprise some to know that Christians support principled autonomy. The Christian emphasis is on duties rather than rights—on personal responsibility rather than personal autonomy. One witness to the Select Committee aptly spoke of,
	"respecting the autonomy of the individual as self-government rather than self-determination".
	But it is not only Christians who believe that they cannot expect to have total control over their life. What they can and must have control over is themselves. If we succeed in doing that—how many of us attempt it, and how many of us do it—life will be better for us and those around us. The inevitability of death has to be accepted, but the manner in which I accept it—not whether I can control its time, place and method—determines whether I die well.
	I want to intervene in my own argument to speak gently to the noble Viscount, Lord Craigavon, who in his otherwise excellent speech charged the right reverend Prelates the Bishops of St Albans and of Oxford with perhaps imposing their view on the rest. If he reads their speeches, he will see that they argue that they want judgment to be made on the rational argument, not on a particular religious point of view. Maybe he is in danger of imposing his view. All of us together have to find a way through the issue.
	Christians and those of many other faiths believe that this life is not the sum total of reality and that they are answerable to God for the way in which they live, die and help others who are dying—not by killing them, but by easing their pain and other suffering. They believe that human life is a gift from God and that we have no right to take it. You may say that most people in Britain today are not practising Christians, so why should Christian values be imposed on others? I suggest that there are many—like my parents when I was growing up—who may not go to church or have a clearly defined Christian faith and structure, but the culture from which they draw their values is essentially a Judaeo-Christian one with an emphasis on compassion, forgiveness and the sanctity of human life. Such values transcend narrow denominational boundaries. They know too that the choice to die cannot be regarded as purely personal and private. It affects other people. To ask a doctor to help to draw your life to an end is to draw that person into your choice in a way that cannot be regarded as morally neutral. It will affect the doctor-patient relationship in a fundamental way.
	Furthermore, even if people do not share the Christian view that euthanasia is morally wrong, many believe that it is misguided; I judge that from the letters that I have received. In that respect, Christian values are at one with good sense and our sense of abiding human values. There are sound secular as well as religious reasons not to go down this road, and I say that with respect to the noble Lord, Lord Joffe. People who argue against changing the law do not do so because they are religious fanatics. Some of them—a substantial number—have religious convictions that tell them that medicalised killing is wrong, but many more can see important civil reasons why society as a whole, especially its more vulnerable members, would be threatened if the law were changed.

Baroness Noakes: My Lords, we are not much beyond halfway down our speakers list. Noble Lords might therefore be glad to know that I have left my prepared speech on the Bench behind me. I will briefly make one or two points.
	My purpose in putting my name down to speak was to bring motor neurone disease to the attention of the House, a subject on which I have spoken before in your Lordships' House. Motor neurone disease is a horrible disease with final stages that many sufferers fear, and rightly so. It ultimately involves complete paralysis, loss of physical control and pain. The real cruelty, however, is that it involves an unimpaired intellect.
	Palliative care for motor neurone disease sufferers, of the quality and in the quantity of which we should be tolerant, is simply not available. I fully support those who say that we should continue to improve the availability of palliative care for all sufferers from terminal illness. Even if we had the most excellent palliative care, however, that would not be sufficient to avoid the need for the Bill. The sufferers of motor neurone disease will lose quality of life and dignity. Not everyone can cope with that. People have different thresholds. Only the individual can make a decision about how great a loss of quality of life they can tolerate.
	I support the Bill, with all the safeguards in it. In doing so, I affirm, as a Christian, the sanctity of life. There is another principle, however, which is the right to a good death. The only person who can decide how to balance life and death is that individual, and it is that individual who should answer to God for that decision.

Lord Cavendish of Furness: My Lords, I have listened to many outstanding contributions this afternoon and the last one, by the noble Baroness, Lady Chapman, is among them.
	My interest in this debate, which I now declare, stems from my having been in the late 1980s among the founders of St Mary's Hospice, Ulverston in Cumbria. I have had continuous involvement with it and am its current chairman. Not unnaturally, I believe with great passion in the work done by hospices in Britain and I also believe that there remains almost unlimited potential for development and innovation in this sphere of palliative care. I and many others touched on that in the debate initiated by the noble Baroness, Lady Finlay, just before the Summer Recess.
	That belief does not blind me to the possibility of the law being improved as it applies to those few people whose suffering is most terrible and intractable and who, in full possession of their reason, wish to terminate their lives. I have no quarrel with the humanitarian motives that lie behind the proposals. However, I would be most uncomfortable if the Bill were to come into law as it stands and even more uncomfortable if it ran its course without serious consideration being given to the concept that palliative care, allowed and encouraged to continue its development, could in fact make the Bill redundant.
	The very distinguished work of the Select Committee under the chairmanship of my noble and learned friend has rightly been widely praised. However, I feel that it was flawed in one respect. The committee travelled and consulted widely but, for reasons I still do not understand, its members did not visit a single hospice. The same point was made by the right reverend Prelate the Bishop of London and my noble friend Lady Cumberlege. Of course, comparisons with other countries and cultures have enormous value, but they also have serious limitations. I would make the point that, whereas consistent threads run through palliative care as practised in British hospices, the GP-driven model as practised in the Netherlands is striking for its difference rather than its similarity. I have no doubt that it works for the Dutch, but we are not legislating for the Dutch or the people of Oregon; we are contemplating a major Bill that affects British people. The committee was of course right to go to Holland and elsewhere; but it would have been better still if it had seen at first hand palliative care as practised here.
	The Select Committee makes the point that however good palliative care is in Britain, its provision is uneven and therefore inequitable. A major contributory reason for that state of affairs which I offer to your Lordships, in case the Minister forgets to, dates back to the wretched and nakedly political action on the part of the Government when they first came to power in 1997 of removing the financial weighting that enabled rural areas to match in quality the services offered by their urban counterparts. That has caused untold harm and difficulty to providers of public service and it is high time it was revoked. I am struck by how little the Minister, who is not in his place at the moment, has to answer today, but perhaps, with his customary helpfulness, he can give me some reassurance when he comes to reply.
	The people covered by this Bill endure the most extreme forms of suffering. It was suggested to the Select Committee that between 3 and 7 per cent of deaths fell into such a category. The experience at St Mary's, the hospice with which I am involved, shows that such extreme distress, which can manifest itself in suffering other than physical pain, is present in about 1 per cent of deaths that occur with us. That is lower than it used to be. The trend is for it to fall still further.
	A combination of increased skills and experience, newer and improved drugs, and an increased confidence on the part of patients and their families that they will not be abandoned—which is a very important phrase—gives me grounds to believe that the suffering that this Bill addresses can in time be removed through the agency of palliative care as practised here in Britain.
	It is claimed by some that doctors and health professionals regularly break the law or at least interpret it liberally in order to relieve suffering. I am sceptical. One reason for my scepticism of such claims is that there has never been to my knowledge even the smallest suggestion by any of our staff that a change in the law would improve our care. On the contrary, it is the unambiguous opinion of our medical director that the accepted definition of patient autonomy has stood the test of time and is not in need of improvement. I sometimes wonder whether the noble Baroness, Lady Tonge, has been in a hospice, because autonomy is central to our philosophy. We consult first and foremost the patient.
	Many noble Lords asked why not have both palliative care and assisted suicide. This debate, which has attracted wide media coverage, is already causing unintended consequences. There is a substantial and increasing incidence of patients arriving at our hospice in varying degrees of agitation. Nothing saddens us more than when they ask anxiously if we are planning to terminate or shorten their lives. It usually takes between 24 and 48 hours before an acceptable level of trust can be restored. After that, usually, no more is heard in that vein. But, in some contexts, 24 hours of fear-induced distress is like a lifetime. Most of our inpatients admitted for terminal care have, on arrival, a life expectancy of up to 14 days. During that time, in an overwhelming majority of cases, the patient and his or her family and loved ones will find safety and comfort. The patient's pain will be controlled and pleasures will be experienced. There will be laughter and a newly won peace of mind is often powerfully evident.
	However well meaning the Bill—and I have no doubt of that—it casts yet another shadow among vulnerable people whose lives have already been shattered by debilitating illness, pain and fear. It has undermined the trust that we so critically need at the moment when desperately ill people turn to us for safe haven. And that is not all. If and when this Bill passes into law, I have forebodings about what might become the culture of the future. Already we talk of an "ageing population". It is possible to picture a new generation, oppressed by a mix of global instability and economic failure, turning on the ageing population whose patrimony we have squandered and whose liability they inherit. In this nightmarish future age, it will become the duty of the old, the ill and the frail to die once they have outlived their economic usefulness. I regret to say that this Bill paves the way for such a future, bereft of all humanity. If that is thought to be fanciful, I suggest noble Lords talk in depth with those who live at the rock-face of palliative care. The truth is that they will find that what I am suggesting is already beginning to happen.
	Echoing the speech of the noble Lord, Lord Carlile, the stark statistics coming from the Netherlands in respect of large numbers of euthanasia deaths occurring without consent, and the alarmingly small proportion of such deaths being reported as Dutch law requires, hardly inspires confidence. Even if these departures from good practice can be explained away, it illustrates vividly how difficult it is to legislate on such sensitive matters and perhaps explains why wiser generations in the past have shown caution. Many noble Lords have spoken about the importance of safeguards. The trouble is that safeguards are at the heart of this matter and, as the noble Lord, Lord Phillips of Sudbury, said, they are elusive.
	I hope that we, too, will tread with caution and divert the entirely benign commitment to relieve human suffering into the field of palliative care, which I believe stands on the threshold of its greatest achievements.

The Earl of Glasgow: My Lords, as a latecomer to this continuing debate on the question of whether in certain circumstances we should legalise "assisted suicide" and/or "voluntary euthanasia", I am most impressed by the amount of time, care and detailed research that has already been done on this very sensitive subject, particularly in the well-considered report from the Select Committee which, in theory at least, we are now considering. I am only sorry that any law that might resolve this issue still seems such a long way away.
	As the noble Earl, Lord Ferrers, reminded us, most of us, to a greater or lesser extent, fear death. As we know, it comes to us all sooner or later—perhaps sooner rather than later for the majority of us in this House. But sometimes I wonder whether it is really death itself that we fear or rather the manner of our death. We fear terminal illness, pain, indignity and, for instance, the inability to perform natural functions without the help of others. We fear becoming a permanent burden. We fear losing our minds and no longer being able to express our feelings and anxieties. The reason is that we have all seen these conditions in others, and it is particularly distressing when we see them in the ones we love. But perhaps our greatest fear is our helplessness, the fact that we will have no control over our own death. It is because I believe that we should have the maximum possible say in the manner of our death that I support voluntary euthanasia, whether administered by oneself or by others.
	The most usual argument against voluntary euthanasia for the terminally ill is that once it becomes legal, it could be abused for selfish or even criminal ends. Old, infirmed grandmothers are often cited as the likely victims: still with a desire to go on living but encouraged, pressurised or bullied into believing that they have become an intolerable burden on the rest of the family, and eventually agreeing to have themselves put down. But as has already been pointed out by other speakers, and has been demonstrated in countries where conditional euthanasia has been legalised, adequate safeguards have been introduced to protect vulnerable people against such situations. The same will surely happen here.
	A much greater threat to the infirmed and terminally ill, and a point mentioned by my noble friend Lady Tonge, is exactly the opposite. It is our desire to keep the ones we love unhappily alive for as long as possible, long after they themselves might have hoped to go. It is for emotional, sentimental, ethical, often self-interested and sometimes religious reasons—not from any fear of the law—that most of us are reluctant to hasten the inevitable death of the terminally ill. Surely, whenever practicable or possible, it should be the wish of the dying person, not that of doctors or even the next-of-kin, that should prevail.
	If your Lordships have not already done so, I recommend—no, as did the noble Lord, Lord Puttnam, who is not in his place at the moment, I insist—that they see a film called "The Sea Within". It is a Spanish film made by Alejandro Amenábar which came out earlier this year and can now be bought on DVD. It is a dramatised version of the true story of Ramon Sampedro, a quadriplegic paralysed from the neck down who became a Spanish cause célèbre when he embarked on a 30-year battle with the Spanish authorities, requesting that they allow him to die, as he put it, "with dignity". In the event, partly no doubt because Spain is a Catholic country, he failed to move them and had to devise a method of having himself put to death in such a way that none of his accomplices could be prosecuted for having assisted him.
	It is a beautifully made film, and not morbid or sentimental. In fact it is quite funny in parts and, through the characters, presents all the arguments for and against euthanasia in a very comprehensive way. There is a particularly poignant moment when one of the characters, a girl who is always by Ramon's bedside and professes love for him, is asked by him to assist in the engineering of his own death. Horrified, she says, "Of course not. I love you". He replies, "No. If you really loved me, you would help me do what I really want".
	We all know what a complex and delicate issue this question of euthanasia is. Every case is slightly different and our own views are largely coloured by our own personal experiences, particularly by the nature of the deaths and suffering of some of the people that we love. But one set of circumstances still seems to me relatively straightforward: a person with a terminal illness, who is still in full possession of his mental faculties but has lost control of all or some of his physical ones, and is clearly not suffering from any form of clinical depression, who wishes, begs, demands assistance to end his life, and persists in this demand for, say, six months, should be given every assistance to have his wish granted, regardless of the views of the doctors or of his family. This surely should be an automatic human right. It is a mystery to me why so many honourable and caring people believe that it is their duty to keep someone alive as long as possible when that terminally ill person has unambiguously stated that that is not his wish.
	I hear that the noble Lord, Lord Joffe, may agree to amend his proposed future Bill to limit assisted dying to those who are not only terminally ill but also suffering unbearable pain. If true, this is an unnecessary limitation and complication. But I will still support all his proposals as a first step in getting the law to accept the important principle of assisted suicide and voluntary euthanasia.

Baroness Murphy: My Lords, we must all be brief today. I want to do no more than indicate my support for the introduction of a very limited Bill to enable those with terminal illness to request help to die.
	I have changed my mind over the past 20 years from being actively against such a measure to being a strong supporter. Indeed, my first letter to the British Medical Journal in 1984, on taking up my chair at Guys, was on this very topic. It would have done credit to the noble Baroness, Lady Finlay; she would have been proud of me. But over the past 20 years, I am afraid, my patients and their families have changed my mind and it has now become a moral issue for me that we should respect the diversity of patients' wishes in the last days of life, just as, as doctors, we are beholden professionally to respect their wishes at other times.
	We have said with some force that we do not always respect an individual's autonomy of action where a decision may impact adversely on others. Certainly we all know that a patient's suicide during a depressive illness can have a profound and widespread distressing impact on other family members, even to the next generation. In practice, however, patients with terminal illness are in a very different position and relatives are almost always sympathetic to the wishes of their suffering loved one, even when they do not agree with the course of action they wish.
	How do I know this? I worked as a gerontologist and psychiatrist in hospital and community services for most of my working life. In hospital practice we have a category called "no psychiatric disorder". This includes those referred by another hospital consultant with a request to "query depressed suicidal thoughts"; patients near the end of long and wearying illnesses who think the time has come to go and feel trapped inside the business of being and yet no longer have the physical means to end it. Of course, if they do, they make their own decision.
	As has already been said, these people are quite distinctive personalities and often not very easy patients. They hate above all the prospect of total dependence on others, detest losing control and are unwilling to sacrifice their individuality to institutional norms. They want to be in charge of their fate and it is the uncertainty about the end that is distressing to an unbearable degree. It is scarcely ever a matter of pain control, although, as we know, there is insufficient expertise in the palliation of pain and the expansion of palliative care services to the very old and those with longer term terminal conditions is long overdue. No, it is not that. What causes their unbearable suffering is not remediable by medicine nor psychological supports but by respecting their wishes and supporting them to choose their own time of death. I can think of no greater privilege, as a doctor, than being trusted to help make happen a person's final wish.
	I remind noble Lords that this limited Bill proposes that a prescription be given and that the person concerned makes the final decision. Most people will be sufficiently helped to feel in control if they just have it available and can think about it. From what we have heard, only a third or so of such people would ever take it. Of course, there are many others. As a psycho-geriatrician, the majority of people I see have treatable, reversible depressions during terminal illness. Others go through periods of hopelessness after diagnosis or after a particularly gruelling course of treatment and come out of it again. You have to sort out one from the other. That requires strict safeguards, but I believe it is possible to make these distinctions, which I hope to address at greater length in some future debate.
	For the moment, I should like to praise the quality of the committee's work, which I found enormously helpful in setting the international scene. Of course those who take the religious view that only God can decide when life begins and ends must always reject the notion of assisted dying. I understand that. But for me and for many others, particularly in those parts of the medical profession that are changing their mind, human suffering demands a human response.

Lord Neill of Bladen: My Lords, I begin with an apology. Regrettably, I had duties to perform in a court of law and could not be here at the start. To some extent, I had the compensation of having heard the noble Lord, Lord Joffe, on the "Today" programme, so I got some of the highlights from him then—and, of course, we have debated this matter before. The other thing to say at the outset is to declare my total absence of any qualification for speaking on this subject; only the fact that I have lived entitles me to speak.
	I hope that the noble and learned Lord, Lord Mackay of Clashfern, will not be embarrassed if I add my voice to what is now a chorus of eulogy for the excellent quality of the report, the manifest skill with which he must have conducted the committee—as one can read between the lines—and also for assembling such a massive body of excellent and very interesting evidence. The only way in which to set the House ablaze at this hour would be if I were to say that I did not think that it was a good report; I would be the first person to say that and it would be an absurd opinion to enunciate.
	The noble Lord, Lord Walton of Detchant, is with us; I have found his earlier report greatly fascinating to go back to. He, too, assembled some great evidence. The House of Lords can be really rather proud of the written record of the testimony that has been established in this field. I have not done the research, but I would guess that it is without parallel anywhere else, as it is really magnificent material.
	I spoke to an earlier version of the Bill, which is recorded in Hansard. My concern was in particular with the vulnerable, and I have not been persuaded that that issue has disappeared or has been taken care of. I want to make a few observations on one or two points.
	It is funny how words can appear on the scene and then assume an extraordinary dominance, as has happened with the word "autonomy". We have been talking about patient autonomy—but I wonder whether I have autonomy as a non-patient. I find that I have not, as I am controlled in everything I do by law and morality, in my profession by an ethical code, and in private life by all the bonds that we all have of love and affection. As for oaths, we have the astonishing Clause 10(3), to which noble Baroness, Lady Cumberlege, drew attention, which means that what is now a breach of an oath will be deemed not to be so. One might ask oneself what Parliament is doing in encouraging people to be false to oaths that they gave on entering a profession. That is very strange—but no doubt a point of detail.
	As I do not believe in non-patient autonomy, naturally I do not find patient autonomy a very convincing idea. It seems to elevate a personal choice in some agonising and heartbreaking cases, such as the noble Lord, Lord Puttnam, described. One could not hear about those cases without thinking that they were absolutely terrible and that it would be marvellous if somebody removed that person from the earth. But one is balancing that against the widespread effects of introducing a Bill, which may subsequently be an Act, along the lines proposed.
	Four areas concern me. First, we know that a lot of the medical profession are strongly opposed to the proposals. What would be the practical effect? Imagine an appointments committee looking for a registrar, perhaps, in a hospital. Would it be legitimate for that committee to ask, "Would you mind telling us how you stand on the assisted dying question? We have had a number of those cases lately. Of course, it is a difficult choice, but this is a very strong field of competition". One can imagine such a situation.
	Secondly, the proponents of palliative care and the hospice movement have given their evidence. There is the evidence from the National Council for Palliative Care in volume two of the report, on page 151—but I need not go into that; if one goes to the fons et origo, Dame Cicely Saunders, one finds:
	"We believe that euthanasia or assisted suicide is socially dangerous and a negative answer to a problem that should be tackled by other means".
	That is a quotation from volume two, on page 101. There is unanimous opposition from the hospices, and this evening we have had the advantage of hearing the direct and compelling evidence from the noble Lord, Lord Cavendish of Furness, who spoke about a particular hospice.
	With regard to the nursing profession, I believe that it is unfortunate that there has been some challenge to the evidence given by the Royal College of Nursing—but nevertheless it seems to be the case that a significant body of nurses want to have nothing to do with the Bill or the ideas underlying it. An interesting sub-issue was raised as part of the nursing evidence, as a very substantial percentage of the nursing profession comes from overseas, and a large number of those come from Catholic countries. So very severe problems might be encountered with the nursing profession in that respect.
	I turn to my fourth category of people whom I am worried about—people whom I then called "the vulnerable". I was rather surprised to see that the people subject to hidden pressures are classified as a sub-head of the slippery slope. As far as I am concerned, they are not on any slippery slope; they are bang on the level with the whole of the proposals. They are an integral part of what is proposed. We have a lot of evidence that people will feel—I am not talking of a Balzac scene of a family persuading an old person that it would be better to sign his or her death warrant—that they should not be here and that they are taking resources from the family. Paragraph 97 of the report states that Dr Jim Gilbert raised the concern,
	"that some patients, while not opting for ending their lives, would feel themselves to be presented, if the law were to be changed, with an ongoing choice to be made".
	"Ongoing choice" are brilliant words—the matter would not go away. A person would be thinking about it six months or nine months later, depending on his or her condition.
	Finally, I am troubled about the safeguards. The very first safeguard at Clause 2(2)(a) states:
	"The attending physician shall have been informed by the patient that the patient wishes to be assisted to die".
	However, the noble Lord, Lord Joffe, said that his intention was that the patient must initiate the request. However, the report points out in paragraph 24 that,
	"nothing in the Bill . . . prohibits a doctor or nurse suggesting assisted suicide or voluntary euthanasia to a patient".
	So the first condition is really a non-condition—simply that the patient says, "Doctor, I have a bit of paper for you. I would like to die", but you do not investigate the prior conversations.
	Like the noble Baroness, Lady Finlay of Llandaff, I was greatly struck by the evidence of the woman reported in volume three who for 10 years, according to her testimony, said that she wanted to die and tried to commit suicide but finally, over the past nine years, has turned into a campaigner for the disabled both in this country and in India. That was a remarkable testimony. If the Bill had been in place, she would have been dead many years ago.

Baroness Emerton: My Lords, I, too, pay tribute to the committee so ably chaired by the noble and learned Lord, Lord Mackay, which produced such a balanced report with clarity on such complex and sensitive issues.
	I speak as a retired nurse with 53 years of experience in the profession. I have two brief points to make from a nursing perspective. First, there is the nurse-patient relationship. Consistently, research shows that 80 per cent of care delivered to patients is provided by nurses. Given that wealth of experience, it is regrettable that their unique position and expert contribution has been omitted from the draft legislation. That is particularly so in the light of evidence that nurses pay a crucially important role in supporting patients and relatives at the end of life, particularly Macmillan, Marie Curie, hospice, hospital and community nurses.
	Virginia Henderson, an eminent professor of nursing from the United States, defines nursing thus:
	"The unique function of the nurse is to assist the individual, sick or well, in the performance of those activities contributing to health or its recovery or to a peaceful death that he would perform unaided if he had the necessary strength".
	I strongly believe that the introduction of a law relating to assisted dying would seriously damage and compromise the nurse-patient relationship, leading to fear of that option at the most vulnerable time in patients' lives. Respect for the intrinsic value of life is central to the nursing profession. Midwives and nurses caring for women undergoing termination of pregnancy have the right to refuse to participate in the procedure on the grounds of conscientious objection. Other nurses do not have, and would not want, that option in these circumstances.
	Secondly, if patients believe that they have no other choice or option but to ask the clinical professions for help in committing suicide, those professions and society have failed them. Palliative care in this country, as we have heard this afternoon, is the envy of the world. We have become skilled in the management of pain and in symptom control, particularly for those with cancer, but we cannot be complacent. We need to continue our research to find new ways to relieve distressing symptoms, particularly for those with neurological conditions.
	It is also important to recognise that palliative care is not just pain control by drugs. "Palliative" derives from the Greek word pallios, meaning "shield". As well as physical care by drug therapy, the psychological, emotional, spiritual or even financial impact of a diagnosis or suspected diagnosis of a disease that might be life-threatening is very much an area where highly trained and skilled palliative nurses can assist a patient through the darkest times with care and compassion towards a peaceful and dignified death, as opposed to the indignity of an unnatural death. Certainly, I can testify to nursing, as a member of a healthcare professional team, many patients under the shield of palliative care, delivering clinical, psychological, emotional and spiritual support within the banner of holistic care. There are of course regrettable circumstances, as described by the noble Lord, Lord Puttnam, but that demonstrates the urgent need for resources for providing high-quality care for the dying.
	The Royal College of Nursing, which represents 370,000 nurses as a professional organisation, opposes the legalising of assisted dying. The noble Viscount, Lord Craigavon, questioned how accurately it represents the total number of nurses. It would be impossible to consult 370,000 nurses and come out with a unanimous answer. It is a majority answer. Certainly, some nurses choose to support voluntary euthanasia.
	The pathway to death is one that we each have to travel. The key to achieving improvements in the care and treatment of dying people is, as a priority, further investment of resources in training for existing and new doctors, nurses and other healthcare professionals, as well as the development of hospice and palliative care, not the introduction of the Assisted Dying for the Terminally Ill Bill.

Lord Lewis of Newnham: My Lords, much of what I wanted to say tonight has already been said far more eloquently than I could hope to do. First, I also commend the noble and learned Lord, Lord Mackay, and the committee on the report, which I found places this very difficult problem in perspective. It is an excellent report and I spent a large amount of my summer reading it and the written submissions.
	I shall briefly discuss two aspects of the report; one is medical and the other concerns palliative care. I was initially favourably inclined towards the Bill. However, having read the report and the evidence that has been given, I now have serious doubts, many of which have been discussed this evening. One of my main worries and concerns is the imposition on the medical community that the Bill will make. Although I have talked to only a limited number of doctors, by far the majority appear to be opposed to any form of assisted dying and worry about the effect it may have on doctor/patient relationships.
	In considering the view of the medical profession, I was particularly impressed by the evidence given to the committee by my noble friend Lord Walton, who has vast experience in medical matters. However, I was somewhat disturbed by what appeared to be a change of attitude on the part of the medical professional bodies in taking a neutral position on this problem—I am not clear what a neutral position to a problem like this can be, but let us carry on. The position was somewhat clarified by the reply that the noble Lord, Lord Walton, made to a question put to him by the committee. He said that in discussions with the president of the Royal College of Physicians it appeared that the procedure necessary to produce a reply would have involved an extensive inquiry. The college felt that it did not have the time to consult its members and so declared a neutral position. I find this perturbing.
	Subsequently, there appeared to be some doubt about the assessment of the opinions of at least one of the other societies concerned; namely, the BMA. I am sure all noble Lords have had a letter about this. Last month, as has already been said by a number of noble Lords, the Royal College of General Practitioners issued a statement indicating that it does not agree with a change in the legislation. I genuinely believe that before any decision is taken on this topic we must have the considered opinion of the medical profession. If time is necessary, time must be given for that opinion to be obtained. It was interesting to compare this evidence with that of the Royal College of Nursing. It appeared, in contrast, to be against the proposal, although I am slightly concerned now with the remarks of the noble Baroness, Lady Thomas of Walliswood, who appears to contest that remark.
	Perhaps I may turn to palliative care. One of the most important points that appears to me to arise is the role of palliative care. The general point made by many of the groups is that with adequate opportunity for palliative treatment, the possibility of near or even complete relief from pain can be achieved. If that is correct, the main point of the Bill appears to be answered.
	A point made by the National Council for Hospices and Specialist Palliative Care Services is that in many cases the delivery of palliative care to patients is performed by general clinicians where the quality of care can be variable. That, it states, leads to bad deaths and unnecessary suffering, a situation that has been noted by those in favour of euthanasia. I think that that illustrates a very important point.
	Although it appears that the UK is in the forefront of countries providing and working in this area, some of the statistics provided in the Department of Health's submission are alarming. These are points which have already been referred to. There are 172 palliative care hospices, of which 75 per cent are in the voluntary sector. They have approximately 2,600 beds. Considering the size of the problem of the number of potential patients in need of such care, this does not seem an adequate set of figures.
	In addition, Professor Higginson from the Department of Medical Law and Ethics at King's College said that,
	"research in the UK into ways to understand patients' wishes about, or to find ways to improve, care at the end of life has been relatively neglected".
	In fact he made the point that less than 0.2 per cent of cancer research money is devoted to that particular area. Clearly funding is essential if we want to carry out this sort of work. Any Bill of the kind we are discussing today is bound to put available resources in other directions; and it has even been suggested that the finances that would be required to implement this Bill could better be utilised in improving the position of palliative care within the community.
	I turn finally to the position that seems to apply to the case for Holland. We have had a lot of discussion about Holland this evening. It is true that with the introduction of assisted dying funding for palliative care initially rose, but my understanding is that it has now dropped and is in a very poor situation. That reflects a very serious matter for concern. The funding of palliative care in this country requires more attention. There is little doubt that there is a need to deal with the problem of pain and death. However, I feel that the proposed Bill reflects the poor position that there is for the correct solution to this problem—a realistic provision of palliative care facilities for those who need the treatment.

Lord Clement-Jones: My Lords, like many noble Lords I took part in the last debate we had on this subject in June 2003. I strongly supported the establishment of the Select Committee although I did not support the Bill. Despite personal experience as a carer, I have tried as dispassionately as I can to test the arguments that I used in that debate against the Bill against the evidence which has been given to the committee.
	In our last debate one of my key arguments was that assisted suicide or voluntary euthanasia would crucially alter the duties of and trust in the medical profession. The overseas evidence from Oregon and the Netherlands taken by the committee is therefore I believe absolutely crucial in this debate.
	As regards the Netherlands, Dr Johan Legemaate, legal counsel of the Royal Dutch Medical Association, KNMG stated that,
	"without a sufficient level of trust, we would never have had the development we have had over the past 30 years."
	Yet other Dutch health professionals claimed quite the opposite. Dr van den Muijsenbergh, a Dutch GP, told the committee:
	"At the level of the patient doctor relationship I see a growing anxiety among terminally ill patients, as well as, other patients, that they think it is not decent not to ask for euthanasia sometimes, because they feel that they are such a burden to their families or to their carers".
	She also talked of the pressures faced by her GP colleagues. Evidence from Oregon from Doctors Hamilton and Toffler was similar in content.
	I therefore still have strong concerns that the traditional role of and necessary trust in doctors would be eroded by the Bill. Then, as many of your Lordships said, we come to the relationship with the availability of palliative care. The crucial argument made by overseas witnesses is that there is a case for assisting dying even where excellent and widespread palliative care is available. But it is far from clear that in the Netherlands or Oregon there is actually good palliative care.
	In the Netherlands, Dr van Coevorden, a GP and part-time consultant in palliative care, does, I grant, described an enormous boom in palliative care training and in hospice care. He considers that that has been stimulated by the law on euthanasia and that such provision is now at a high level. But the fact is that other witnesses had a completely contrary view. It appears that the boom in training courses in palliative care was the result not of the legislation but of the prior debate about voluntary euthanasia. The funding for research and training is now in fact diminishing. As we heard from the noble Baroness, Lady Finlay, there are no full-time palliative care posts in the Netherlands at all. Dr van Coevorden himself admitted that if you give proper care, you will see requests for euthanasia fall. Some of those giving evidence alleged that Oregon also has extensive palliative and hospice care and that it has grown substantially, but other evidence, such as that from Professor Katherine Foley of the Sloane-Kettering in New York, completely contradicts that.
	So the suspicion remains that palliative care has not been fully developed in either Oregon or the Netherlands. However, as we have heard in the debate today, massive strides in palliative care have been made in this country during the past five years. Even the past year has seen major advances. Surveys show that palliative care doctors themselves are overwhelmingly opposed to the proposals. Should we not, as many noble Lords have said tonight, be concentrating on ensuring that patients have the best palliative care and developing adequate resources in the NHS and in our hospices? As palliative care doctors can testify, all patients have moments of despair, even the most positive, as I can testify from experience.
	However, in the words of one US doctor who gave evidence to the committee:
	"Patients can be given a sense of control without being handed a deadly weapon".
	The burden of proof is on the supporters of the Bill and, after consideration of the evidence taken by the Select Committee, I do not believe that the right to get professional assistance in handling one's own death has been made out. I do not support going forward with the Bill.

Baroness Young of Old Scone: My Lords, it is quite late and I thought that I might just stand up to say that I support the Bill tabled by the noble Lord, Lord Joffe, and sit down again. That would certainly make half of your Lordships very happy for the support and the other half of you very happy for the brevity, but I want to say a little more on this important topic. I am very grateful to the Select Committee for giving us this opportunity to debate it. Like my noble friend Lord Puttnam, I should like to focus on individuals rather than on doctors, nurses or churches: to focus on people.
	We all die. Some of us will die better than others and, for painful and difficult deaths, palliative care can help and certainly needs improvement in its quality and distribution in this country. In my previous existence I was involved in the enlargement of palliative care, but I do not believe that it is enough. It is not enough for control freaks—the noble Baroness, Lady David, was very unhappy about being designated in that way—who, after a lifetime of trying to control their lives may find themselves at the end of it unable to control it. I include myself in that category.
	The other group of people on whom we have not focused enough is those with long-standing terminal diseases for whom the dread of a terrible death threatens to blight even the comparatively disease-free part of their lives. A few years ago, a group from your Lordships' House were privileged to hear from a young woman with early motor neurone disease. She had experienced her mother's lingering death from the same condition. Despite support and palliative care, it was a horrible death for her mother and for the family. The young girl now faced a long decline in her own health in the same way, with clear knowledge of what lay in store for her in the future. She desperately needed the comfort of knowing that when her time came she could make a choice in order to avoid going through that terrible sort of death. The Bill introduced by the noble Lord, Lord Joffe, would give her that lifelong comfort.
	In the debate, we have heard a lot about the sanctity of life and the preciousness of the gift of life. But I believe that life is no longer sanctified or precious if the holder has come to the point where life is no longer seen as a precious commodity. We have heard a great deal about respect. The noble Baroness, Lady Greengross, summed it up when she said that a dying person should not have to beg for his or her wishes to be respected. A dying person should not have to save up his or her drugs surreptitiously and risk an amateur and botched suicide. A dying person should not have to travel abroad to die among strangers. That is not respect.
	The Bill is a very carefully crafted set of proposals. I very much admire the thoughtful way in which the noble Lord, Lord Joffe, has conducted the drafting and his commitment to amend it to best meet the widest possible range of views. It contains multiple safeguards against misuse. It deserves our and, indeed, the Government's support.

Lord Lipsey: My Lords, my first-ever public speech, in the Oxford Union nearly 40 years ago, was in support of euthanasia, an issue about which I have thought again only this summer. Since I made that speech, the argument has moved forward in two significant regards. The first, much remarked on tonight, is the improvement in our care of the dying— stronger drugs for pain control, a greater willingness on the part of doctors to prescribe them to those who need them, and the wonderful growth of the hospice movement although it is common ground on all sides of the House that we need to do more to improve palliative care and hospice care.
	The other factor, which has not been remarked on, is that the diseases that used to carry people off to a merciful death are now terribly treatable—pneumonia, for example, the old man's friend. People with the most appalling neurological afflictions in particular can linger on and be kept alive by modern medicine for years and years.
	Those two arguments point in contrary directions and they are as difficult to weigh today as they were then, although the Select Committee has done a wonderful job in putting the considerations on every side. While I am balanced in favour of change, I am much concerned about the notion that old people will somehow feel obligated to end their lives out of a false sense of the burden which they are imposing on others.
	I want to draw one contrast between those who favour a change in the law and those who do not. The noble Lord, Lord Joffe, whose efforts are commended even by those who strongly disagree with him, is a very rare creature. He is a man who changes his mind in response to evidence. I know this because I sat with him on the Royal Commission on Long-Term Care of the Elderly, and he was persuaded there to drop his original predisposition in favour of spending money on better care rather than providing it free to the better-off. He has changed his mind quite a bit on this Bill—I am not sure he is right to have done so—to put in additional safeguards.
	I am afraid that the same does not apply to most of the opponents of the Bill. The right reverend Prelates the Bishop of Oxford and the Bishop of London both told us to listen to their arguments. The trouble is that I suspect that, whatever was done to refute or demolish those arguments, they would still hold the same position, which is deeply rooted in their faith. They are entitled to have that opinion, but we should recognise that difference between the proponents and opponents.
	I do not therefore have any hope of convincing those fundamental opponents, but I would just make to them two incredibly simple points at the end of a complex and subtle debate.
	First, I respect and enormously admire people's willingness to declare for themselves that however ghastly their sufferings at their end—and for all that palliative care can provide, it cannot alleviate every suffering; we have heard from noble Baroness, Lady Noakes, about motor neurone disease—they commit themselves in advance to accepting those sufferings, because that is in accord with their belief. What I cannot respect and admire is their willingness to impose their commitment on others, using to do so the law of the land, a land that is increasingly a secular land that does not share those particular values.
	Secondly, although I am no theologian, it seems to me as a simple soul that to condemn many of your fellow human beings to an agonised, undignified and unchosen end in the name of your abstract principles is a bit unchristian.

Baroness Howells of St Davids: My Lords, I, too, add my congratulations to the noble and learned Lord, Lord Mackay, for his balanced report. I intend to place on record why I am deeply unhappy with the Bill that the noble Lord, Lord Joffe, intends to present. Those reasons are such that I am unlikely to support any future Bill on this subject, because I envisage the negative fallout on the poor and on the black community in particular. Will this Bill be used later as a form of ethnic cleansing?
	There is one certainty in life and that is death. It is final. There is no turning back. I urge the House to support the old-fashioned notion to let nature take its course. One of the most striking features of any assisted dying Bill is its lack of contact with the real world. It depicts people who are wholly rational, who have thought long and hard about ending their lives and who have access to good palliative care. But that is not the real world. Most people who receive a terminal prognosis are at a very irrational stage of their lives. Most have not thought about ending them at all. Why should they have done so? Many of them do not have access to the best palliative care and, above all, they are frightened and confused. It is all very well for any Bill to talk about referring people for psychiatric assessment if there appears to be a psychiatric disorder or offering them a palliative care assessment. But anyone who knows anything about the matter will tell you that in a multiracial society doctors often cannot spot depression and internalised pressures and that hearing about good palliative care is a world away from experiencing it.
	There is another way in which the Bill falls short of reality. My attention was caught by a statement made to the committee by one of its witnesses—Professor Irene Higginson of King's College, London. Professor Higginson, who specialises in palliative care, told the committee:
	"There are certain under-privileged communities which have lower access to palliative care services".
	She continued:
	"Work that we have done in the south London area has shown a mixed experience in advanced cancer, for example, among the local black Caribbean community".
	And reports showed, said Professor Higginson,
	"a trend towards a greater number of unmet needs and also reports of less satisfactory care . . . compared to a local white UK-born population".
	Is assisted dying the answer?
	Noble Lords may ask what this has to do with euthanasia. The answer is simply this: the more disadvantaged that people are in accessing palliative care services, the greater the push for them to access assistance with suicide or euthanasia. Let us look at what the Select Committee was told when it visited Oregon to inquire into the working of the so-called Death with Dignity Act. The Oregon health department, which collected data on the numbers and characteristics of people who opt for medical assistance with suicide, told the committee:
	"Asians are about three times more likely than whites",
	to take lethal drugs supplied by a doctor to help them out of their confusion.
	I want to look at another aspect of this matter, and I am glad to see that the committee flagged this up clearly in its report. Society does everything possible—and rightly so—to prevent or frustrate suicides, yet here we are considering whether one group of people—the terminally ill—should be aided and abetted in killing themselves.
	I have long been concerned about suicides among prisoners—especially among black prisoners—and about the watch that is kept on them to prevent tragic and ill-considered actions. What kind of signal will it send to prisoners who are suffering—and many of them are, in the words of the Bill of the noble Lord, Lord Joffe, "suffering unbearably"—if we decide that such suffering is a key criterion for being helped to end one's life rather than being discouraged from doing so? Not only is there a complete inconsistency here, with society facing in opposite directions, but in my view there is a risk that over time this will translate, however subtly, into less rigorous oversight of suffering prisoners. It is no good to say that we are talking here only about the terminally ill; a Rubicon will have been crossed, and it would be less than realistic to expect there to be no impact on other situations of unbearable suffering.
	Finally, what about nurses, of whom mention has already been made? The report says much about the problems of doctors but precious little about the effect on nurses. Community nurses see dying people all the time. They could not withdraw from participating in this law without withdrawing from the nursing profession. It is all very well to say that there will be a conscience clause but, in reality, many nurses will fear for their jobs if they are seen to be unco-operative, and the likelihood is that they will either find jobs other than nursing or take their skills abroad. The Royal College of Nursing pointed to the high proportion of trained nurses in the UK who come from cultures which are hostile to euthanasia, and predicted a haemorrhage of trained staff if a Bill like this were to become law. I ask the House: is this really what we want in the UK.

Lord McColl of Dulwich: My Lords, I too pay tribute to the skill of the noble and learned Lord, Lord Mackay of Clashfern, whose wisdom and good humour have proved to be essential. In summing up from these Benches, I should say that the leader of our party, Michael Howard, is strongly opposed to the Bill, but of course there will be a free vote.
	I have enjoyed the debate. As usual, I have learnt a great deal from your Lordships, and, as always, I appreciated the noble Lord, Lord Maginnis, putting things in perspective, especially at the very beginning and at the end of life. We doctors can be carried away with enthusiasm, like the paediatrician who said in a lecture, "The first few minutes of life are the most dangerous". An old man from the back shouted out, "The last few minutes are pretty dangerous, too".
	My noble friend Lady Flather has invited me to mention my experiences in Holland to reinforce what the noble and right reverend Lord, Lord Habgood, said. I asked a Dutch doctor what it was like doing his first case of euthanasia. "Oh," he said, "we agonised all day. It was terrible". However, he said the second case was much easier, and the third—I quote—"was a piece of cake". That left us feeling cold.
	When the noble Lord, Lord Joffe, introduced his Bill, he said that he recognised that it should not place vulnerable members of society at risk, nor compel doctors or other members of medical teams to participate in processes to which they have a conscientious objection. My fear is that the Bill will fail in both those respects. A Bill legalising euthanasia or assisted suicide would be a radial change in our law. The so-called safeguards are anything but safe. They are rather like banisters along the side of a high staircase that look fairly sturdy from a distance but give way when they are leant upon for support. As my noble friend Lady O'Cathain said, the risk of undiagnosed depression is very real and depression is common among the terminally ill. The risk of misdiagnosing terminal illness is also real. The Royal College of Pathologists told the committee that that sort of misdiagnosis occurred in about five per cent of cases. Yet, if a depressive illness goes untreated or a non-terminal illness is wrongly diagnosed, no one will ever know or be able to do anything about it, for the simple reason that the patient will be dead.
	The Bill does not even require the physician who certifies that the patient complies with the safeguards to have any previous knowledge of the patient, nor does the Bill allow or require the physician to consult others who know the patient, such as his or her family. Then there is the danger that what appears to be a voluntary request to die is no such thing. If the Bill is passed, it will start a process over which we have no control and from which there will be no turning back. It is likely to cause a subtle change whereby it is expected of the elderly and vulnerable that they should opt for assisted death. The elderly and vulnerable should never have to justify their continued existence to others, nor should they have to justify their continued existence to themselves. How voluntary is a request that is made against a background of expectation created by the Bill, an expectation that the vulnerable will chose death over life?
	The present law is not perfect, but it makes a clear distinction between the removal of treatment allowing nature to take its course on the one hand and the active commission of death on the other. The Bill removes the clear line and in its place introduces fuzzy lines that are arbitrary. As the noble Lord, Lord Phillips of Sudbury, asked, how does one objectively assess unbearable suffering? If it is a reason to end the life of people who are expected to die shortly, how long will it be before it is argued that it should be applied to others whose suffering can be expected to last longer? The new lines drawn by the Bill are liable to shift, as the noble Lord, Lord Turnberg, said.
	The law as it stands does not allow the patient to demand medical treatment that his doctor does not regard as medically indicated, but the Bill creates two exceptions to that rule. Assistance with suicide and the lethal injection will become treatment options that the patient can demand and the doctor cannot refuse, provided that the checklist of so-called safeguards can be ticked.
	It is no comfort to point to the conscience clause. At best, it will be divisive and, at worst, it will be ineffective in protecting would-be physicians who will probably opt out of geriatric care, just as those who rely on a similar clause in the Abortion Act have opted out of gynaecology. The noble Lord, Lord Neill of Bladen, speculated about the questions that would be asked of somebody applying for a job. How right he is; that is exactly what happened over the Abortion Act. The question that was asked of would-be obstetricians and gynaecologists by interviewing committees was whether the candidates would be prepared to take their share of abortions. If they said "Yes", they were considered for the appointment; but if they said, "Yes, I will act within the law", they would be excluded. Hundreds of midwives and obstetricians had to emigrate because they were discriminated against in that way.
	Engineers are trained to design potentially lethal machines to fail to safety. For example, a thermostat that monitors the temperature on a heated oil tanker will be designed so that should it fail the heating element turns off, thus avoiding the possibility of overheating and explosion. The law as it stands now fails to safety. It errs on the side of prolonging life and protecting the vulnerable. For all its intended safeguards, the Bill will not fail to safety. The present law errs on the side of life; this Bill will err on the side of death.
	Today the noble Lord, Lord Joffe, indicated that he proposed a new Bill that will relate to assisted suicide but not euthanasia. I fear that that revision is mere expediency. Imagine the reality. If I, as a doctor, place a lethal pill in a patient's hand and he swallows it, that would be legal; but if I place the pill on the patient's tongue a few inches away, that would be murder. One cannot make laws on that basis. The two acts are morally equivalent.
	There have been several mentions of the double effect. It is important to stress that that is generally misunderstood. The medical profession has been accused of hypocrisy, and it is alleged that we give patients, say, heroin to relieve their symptoms but really what we are doing is killing them. People who make such criticisms are ignorant of the elements of pharmacology. The dose required to relieve a symptom is a fraction of the dose required to kill, which, after all, is the definition of a good drug. It is called the therapeutic index. What Cecily Saunders did so brilliantly was that she realized that the answer to relieving symptoms was to keep a constant level of drugs in the blood so that the patient was kept free of pain but was able to enjoy life; whereas in the old days we waited until patients got pain and then gave them a slug of heroin, which put them out for a while. When they surfaced and got the pain again, they would have another injection. That intermittent regime had its problems. So there is no hypocrisy at all.
	When a patient comes into a hospice, it takes about 24 hours to settle the various doses of drugs to deal with the anxiety, to deal with the pain, and to deal with the breathless. Once the dose, say, of heroin has been fixed, it stays at that dose largely until the patient dies. So the idea that doctors are killing patients in this way is certainly not true.
	Finally, I am glad that the noble and right reverend Lord, Lord Carey, stressed that religious views should not be excluded from the euthanasia debate. I have never tried to impose my Christian views, but what I have done on debates on euthanasia and in articles that I have written is to quote a TV programme shown on the much maligned BBC. It was called "Five Steps to Tyranny", and it brought together all the scientific and historical evidence that led to the conclusion that,
	"we are all capable of doing the most appalling things to other people".
	That was not a religious programme; it was a secular programme. The law is a great dam holding back the wildest excesses of the wild men, but it also holds back the potential for evil inherent in mankind. However careful and thoughtful the noble Lord, Lord Joffe, has been, many regard his Bill as a crack in the dam that could put in danger the elderly, the vulnerable and the dying: the very people most in need of protection.

Lord Warner: My Lords, I am grateful to the noble and learned Lord, Lord Mackay of Clashfern, for introducing this debate. It has provided a chance for this House to continue the important debate on how people should be treated as they reach the end of their lives. I join other noble Lords in saying that the noble and learned Lord and the members of the Select Committee have done an excellent job in assimilating an impressive range of evidence in such a challenging area, and I will comment further on their report a little later.
	In the available time, I cannot respond to all the individual points made by speakers. First of all, I want to acknowledge the strong and sometimes opposing views that we have heard today. These reflect the strength of feeling held on this issue within society and the Government are well aware of the differences of opinion and belief and the reasons behind them. I also want to acknowledge Parliament's role in considering issues of this nature. In our response to the Select Committee, the Government stated:
	"It is appropriate that Parliament should lead on debates of this nature and provide the forum where all shades of opinion can be heard".
	The wisdom of your Lordships has been, and will continue to be, particularly valuable in this respect.
	As many noble Lords have said, we are not alone in having this debate. Other countries are considering similar issues. For example there were debates in California about a Death with Dignity Act earlier this year; a private Member's Bill to legalise assisted suicide in Canada has been introduced recently; and, as has been mentioned, the Council of Europe has considered issues about assistance at the end of life in detail, although I understand that it rejected the idea of active euthanasia. I am aware that in Scotland there has been a consultation on a draft proposal for a private Member's Bill to allow capable adults with a terminal illness to access the means to die with dignity.
	As several noble Lords said, it is more than 10 years since the House of Lords Select Committee on Medical Ethics reported on euthanasia. It is pertinent to have the debate again and on a more specific aspect and in the light of experience elsewhere—for example in Oregon and the Netherlands, from which noble Lords draw differing conclusions. In 2003, this House debated the Patients' Protection Bill introduced by the noble Baroness, Lady Knight, and the earlier Bill of the noble Lord, Lord Joffe.
	Last year, the House decided that a Select Committee should be established to consider the revised draft of the noble Lord's Bill and I feel that those who served on the Select Committee have demonstrated the wisdom of that decision. I want to commend the Select Committee on such comprehensive evidence gathering; on handling such a difficult issue with sensitivity and balance and on producing such a comprehensive report. Like other noble Lords, I congratulate the noble and learned Lord, Lord Mackay, on steering that process with such fairness and skill.
	I well understand the persistence of the noble Lord, Lord Joffe, on this issue. There is no doubting his compassion and integrity, but it is clear that others are equally committed to opposing views. This private Member's Bill raises profound and complex ethical questions and it is right that the Government take a neutral stance while we listen to the debate on the Select Committee's report. Neutrality continues to be our position.
	I was especially interested to hear of the reality in places where this sort of legislation has been introduced—for example, on the differences between Oregon and the Netherlands. The report makes clear that there seems to be general agreement that there are a number of people,
	"who might be regarded as serious about ending their lives, who are not psychiatrically ill and who are unlikely to be deflected from their purpose",
	and that that number is very small. Equally importantly, the report details the concerns of groups who fear that any legislation in this area could result in pressure on people who do not fall into this group to seek to end their lives. It also highlights the need for stringent safeguards in any future Bill. Many noble Lords have emphasised that point today.
	I was also interested in the picture presented of public opinion—a very interesting contribution was made by the noble Lord, Lord Moser—and that of healthcare professionals. The report quotes a number of polls that show public support for the principle of assistance to die—for example, the various British Social Attitudes surveys showing rates of between 75 per cent and 82 per cent in favour. But it also gives a valuable health warning that such figures cannot be taken conclusively as the considered view of the UK public. Healthcare professionals' views are, of course, important, as many noble Lords have indicated, because they will have much more direct knowledge of the realities involved. It is interesting to note the report's point that,
	"It seems likely that medical professionals view the issue of the legalisation of euthanasia as less straightforward than the lay public".
	All of those aspects must be weighed carefully as we consider the way forward.
	A feature of the debate has been the number of times that noble Lords have raised issues around palliative care and have paid tribute to the advances made in this country. Patients need good symptom control. The Government recognise the importance of providing effective and efficient palliative and specialist palliative care services. Thanks to people such as the noble Baroness, Lady Finlay, and I should add, the Government's support, we have made much progress in this field over recent years. I certainly pay tribute on this occasion to those working in this area and I accept that we need to do more. That is why we are investing an extra £50 million per annum in specialist palliative care services. This substantial increase in NHS funding for specialist palliative care—about 40 per cent more than 2000 levels—provides direct benefit to patients.
	In 2003-04, more than half this extra money went to the voluntary sector, mainly to hospices to support their valuable existing work and to expand that work. Nationally, the additional £50 million has so far funded 38 new palliative medicine consultants, 143 new clinical nurse specialists and 38 new specialist palliative care beds, which is a pretty good start. Between 2001 and 2004, we invested in training about 10,000 nurses and other health professionals who were not specialist in the principles and practice of palliative care.
	The relief of pain has been mentioned in this debate on many occasions. A recent National Audit Office survey showed that in 2004 five out of six cancer patients thought that hospital staff had done all they could at all times to relieve pain, while more than nine out of 10 felt they were given enough medication or other help to deal with pain after leaving hospital. In both cases, patients' experiences were a real improvement on the position reported in 2000. Clearly we would like those figures to be better, but I would suggest that great improvements are being made in that area as a result of hard work by NHS and voluntary sector staff.
	Choice in palliative care and end-of-life care are key areas that we are working on. In our general election manifesto we said that we would increase the choice for patients with cancer and double the investment going into palliative care services, giving more people the choice to be treated at home. I have to say that I do not recall any other parties giving such a commitment. The details of delivering our commitment are being worked through in consultation with a wide range of opinion. I am sure that in this process we will look at the points concerning rural services made by the noble Lord, Lord Cavendish, and the kind of health inequality issues that my noble friend Lady Howells made. Our commitment will help us to improve end-of-life care for children as well as adults.
	The views of the public, service users and staff on end-of-life care issues will be an essential element of the important consultation exercise we are currently engaged in: Your health, your care, your say. We want to hear what people have to say and we will take account of what they tell us in the way that we discharge our manifesto commitment on palliative care.
	It is always worth bearing in mind that there is little point in consulting the public on end-of-life issues and then being unwilling to listen to what is said. We know that the public want more personalised healthcare and that this is likely to extend to end-of-life issues: how people can die with dignity and in their own way. The importance of patient choice and personal autonomy is a central theme throughout the work of the Department of Health and will continue to be such a theme, despite some of the considerations raised today. It is right that we, both individually and as a society, should ask ourselves how we feel about and respond to the issue of helping someone to end their life. The sad cases raised by a number of noble Lords where people request help with dying challenge deeply held moral beliefs about the value of life and the qualities themselves which make it valuable. As some have argued today, it challenges the very idea of the sanctity of human life. But in a diverse, multicultural and often secular society, which is the one we live in today and which rightly recognises the dignity of all citizens and their right to make autonomous choices, we have to consider those aspects as well.
	However, patients increasingly have access to information about their healthcare and exercise their right to make decisions about the treatment choices available to them, including declining interventions where to them this seems appropriate. We know that the rights to individual liberty must be balanced in part against the freedoms and interests of other members of society, an aspect raised by a number of noble Lords. Thus perhaps the ultimate decision that a person can make, to control the time and manner of death, is not a purely personal one. This debate forces upon us the contested question about whether patients, by exercising that very autonomy, should have a right to ask for and receive help to die from doctors whose prime task, as has rightly been said, is to heal. Thus, it could be said that such requests could damage the fundamental trust between doctor and patient, although I would suggest that acting to relieve unbearable suffering for terminally ill patients could also represent a final act of care and respect. On the other hand, experience in other countries shows that some members of the medical profession are willing, on a voluntary basis, to assist people who have made a well informed and personally determined choice about dying with dignity at a time of their own choosing instead of continuing with a painful existence that they consider unbearable or intractable.
	These are complex arguments that the Government feel they need to listen and consider carefully from a position of neutrality. Our role as parliamentarians, among other things, is to gauge and reflect society's views in all their diversity. We are here to develop sound policies and laws that may need to move with the times if that is required for a particular issue, but we must not be afraid to maintain the status quo if, despite different viewpoints, that is what we judge to be fundamentally in the best interests of society as a whole. Above all, we have a duty to protect the vulnerable and to ensure that any measures for change we do promulgate bring benefit and not harm.
	It was helpful that in introducing his revised Bill the noble Lord, Lord Joffe, set some clear parameters for the debate. For example, his Bill concerned itself with competent people only and those who are terminally ill. This helps to focus the debate more clearly. As the Select Committee report highlights, a number of issues arise around the use of terms and how they are defined. It is clear that robust safeguards will be vital in any Bill that is reintroduced. The committee has also made a useful distinction between assisted suicide, when a doctor provides the means to allow a patient to end his own life, and voluntary euthanasia, when the patient needs the physical help of a doctor to do so. For the purposes of legislative clarity, the two should be addressed separately. It also highlights the difficulty of dealing with the qualifying terms in legislation.
	I imagine that those drafting any future Bill would want to reflect on the detailed consideration that the Select Committee has given these points and the points that have been raised in the debate.
	I conclude by repeating my thanks to the Select Committee for the valuable piece of work it has carried out in producing this balanced and comprehensive report and to all noble Lords for the important and considered points made today. This is a profound issue that deserves careful scrutiny. The quality of argument and the intensity of the views expressed have done full justice today to the subject. I have little doubt that we will return to this subject as many in an aging society think more about end-of-life issues and how they can leave this world in a manner that is dignified and reflects their personal values. The noble Lord, Lord Joffe, seems likely to ensure that we will do just that.
	However, in response to the question about government time for a Bill, posed to me by my noble friend Lord Carter and others, I remind him and them that we have a busy Session in both Houses. Let me reassure the noble Lord, Lord Patten, that the Government have not signalled that time will be given for a future Bill and I am not doing so today. In this House allocation of time is a matter for the usual channels, thankfully, and not for me. I hope that I have achieved a suitable degree of inscrutability in my remarks, consistent with the Government's position of neutrality on this issue. On that note I conclude my remarks, despite attempts by several noble Lords opposite to get me to go further.